
Copyright N°^ 



COPYRIGHT DEPOSIT: 



SURGICAL DISEASES 
OF THE CHEST 



CARL BECK, M.D. 



PROFESSOR OF SURGERY IN THE NEW YORK POSTGRADUATE MEDICAL SCHOOL AND HOSPITAL ; 

VISITING SURGEON TO THE ST. MARK'S HOSPITAL AND THE GERMAN POLIKLINIK ; 

CONSULTING SURGEON TO THE PHILANTHROPIC HOSPITAL; PRESIDENT OF THE 

AMERICAN THERAPEUTIC SOCIETY ; PRESIDENT OF THE NEW YORK SOCIETY 

OF MEDICAL JURISPRUDENCE; FORMERLY CHAIRMAN OF THE 

SURGICAL SECTION, INTERNATIONAL CONGRESS OF ART 

AND SCIENCE, ST. LOUIS, SEPTEMBER, 1904, ETC. 



Mitb 16 Colored anfc 162 Qthct IMustrations 



PHILADELPHIA 

P. BLAKISTON'S SON & CO. 

1012 WALNUT STREET 
1907 



LIBRARY of CONGRESS 
Two Cooies Received 

APR, t 1907 

. Copyright Entry 
CLASS A XXC, No/ 
foOPY 3.' / 



TU 



Copyright, 1907, by P. Blakiston's Son & Co. 



DEDICATED TO 

professor ^incen^ C^rrnp 

THE GREAT TEACHER AND FRIEND OF MANY 
AMERICAN SURGEONS. 



PREFACE. 



The wonderful progress of modern surgery has given an 
impetus to a production of special literature unheard of in the 
history of surgery, every organ of the abdominal cavity being 
the subject of at least one large and excellent treatise. It 
seems that the especially technical achievements of American 
surgeons, whose brilliancy has become most striking in ab- 
dominal surgery, absorbed all interest and concentrated it upon 
the abdominal cavity. This may account for the fact that other 
cavities of the human body, especially the thoracic, are in spite 
of their immense importance treated as a quantite negligeable. 

Nothing illustrates this state better than the fact that up to 
the present there is only one special work on the surgery of the 
chest. It is from the illustrious pen of Stephen Paget, who 
must properly be considered one of the pioneers in this great field 
of practice. But since the publication of his book, which bears 
the date of June, 1896, three great factors have arisen which 
transformed the character of surgical work to such an extent 
that many traditions and theories had to be discarded. These 
three revolutionists, which led to surgical possibilities hitherto 
not dreamed of, were: Bacteriology, Asepsis, and the Rontgen 
Method. 

I have endeavored to emphasize the great importance of 
these new branches of science without ignoring the notable 
researches and the valuable experiences of our ancestors. At 
the same time I have taken pains to make the book especially 
useful for the general practitioner by accentuating the border- 
line character of the work. Consequently more stress is laid 
upon diagnostic points than is generally expected from a 
book of a distinctly surgical character. 



vi Preface. 

I am greatly indebted to Messrs. Wood & Co. for the 
blocks of some of my illustrations printed in the "Medical 
Record." My thanks are also due to Professors Waldeyer, 
Testut, Jacob, Garre, Lejars and von Winckel for their courtesy 
in allowing me to copy some of their excellent illustrations. 
The other illustrations are originals depicted from cases treated 
by myself in the Postgraduate and the St. Mark's Hospitals. 

Most of the Rontgen illustrations were taken by my son, 
Dr. Eric Carl Beck. I am furthermore under special obliga- 
tions to my wife for preparing bibliography and index and for 
other valuable assistance. 

Carl Beck. 

New York, 37 East 31ST Street, March 27, 1907. 



CONTENTS. 



CHAPTER I. 

PAGE 

The Anatomy of the Thoracic Wall and the Diaphragm i 

General Outlines i 

Sternum 6 

Ribs 10 

Thoracic Vertebrae 16 

Ligamentous Connections of the Thoracic Bones 24 

Interchondral Articulations 28 

Muscles, Vessels, and Nerves of the Thoracic Wall 29 

Diaphragm 40 

CHAPTER II. 

Surgery of the Thoracic Wall 43 

Malformations of the Thorax 43 

Injuries of the Thoracic Wall (Non-penetrating) 61 

Asepsis 61 

Fracture of Sternum, Rib, and Costal Cartilage 68 

Burns of Chest 73 

Contusion of the Thorax Associated with Injuries of the Intra- 
thoracic Organs 82 

Penetrating Injuries of the Thorax 83 

Inflammatory Processes of the Chest-wall 86 

Phlegmon of the Thoracic Wall, Genuine and Tuberculous Ab- 
scesses ; Necrosis 90 

Injection of Iodoform-glycerin 99 

Tumors of the Chest-wall 101 

(1) Benign Growths 101 

(2) Malignant Growths 105 

(3) Hodgkin's Disease 108 

(4) Echinococcus of the Chest- wall 112 

CHAPTER III. 

Intrathoracic Diseases 114 

Anatomy of the Pericardium 114 

Injuries of the Pericardium no 

Aspiration of the Pericardium 116 

Pericardiotomy 1 iS 



viii Contents. 



PAGE 



Anatomy of the Heart 120 

Injuries of the Heart 122 

Anatomy of the Pleura t 125 

Diseases of the Pleura 128 

Serothorax (Serous Exudative Pleuritis) 129 

Aspiratory Puncture of Thorax 132 

Exploratory Pleurotomy 133 

Pyothorax (Empyema Pleurae) 137 

Hydrothorax 201 

Hemothorax 201 

Chylothorax 202 

Anatomy of the Lungs 203 

Abscess of the Lungs 206 

Gangrene of the Lungs 211 

Bronchiectasis 213 

Echinococcus of the Lungs 2 14 

Actinomycosis of the Lungs 217 

Tuberculosis of the Lungs ". 219 

Intrathoracic Tumors 222 

Aneurysm of the Thoracic Aorta 226 

Anatomy of the Trachea and Bronchi 236 

Foreign Bodies in the Respiratory Passages 239 

CHAPTER IV. 

The Value of the Rontgen Method in Thoracic Surgery 246 

General Rules 246 

Localization of Abscess, Bronchiectatic Cavity, Echinococcus, and 

Gangrene of the Lungs 249 

The Rontgen Method in Pleuritis 256 

The Rontgen Method in Pyothorax 257 

The Rontgen Method in Hydropneumothorax 258 

The Rontgen Method in Diseases of the Heart 258 

The Rontgen Method in Diseases of the Pericardium 259 

CHAPTER V. 

Subphrenic Abscess 261 

Topography 262 

Pathological Anatomy 267 

Diagnosis 268 

Prognosis 273 

Varieties 276 

Course 284 

Therapy 285 



Contents. ix 

CHAPTER VI. 

Diseases of the Breast 290 

Anatomy of the Breast 290 

Diseases of the Nipple 292 

Inflammatory Processes in the Breast (Mastitis) 294 

Mammary Cysts 304 

Special Inflammatory Processes in the Mammary Gland 305 

Echinococcus of the Mammary Gland 306 

Mastodynia 307 

Hypertrophy of the Breast 307 

Tumors of the Mammary Gland 308 

Adenofibroma of Breast 310 

Adenoma of Breast 311 

Lipoma, Atheroma, Myxoma, Angioma, Chondroma, and Oste- 
oma Mammae 311 

Sarcoma Mammae 312 

Carcinoma Mammae 314 

Operative Treatment of Carcinoma Mammae 321 

Rontgen Treatment of Carcinoma Mammae 335 

Rontgen Treatment of Benign Diseases of Chest 348 

Index 369 



SURGICAL DISEASES OF THE CHEST. 



CHAPTER I. 

THE ANATOMY OF THE THORACIC WALL AND 
THE DIAPHRAGM. 

The thorax has a conical shape, its convex walls represent- 
ing a barrel-shaped osseous structure which is formed by the 
ribs, the dorsal vertebrae, and the sternum. The axis of this 
osseo-cartilaginous cage shows an oblique downward and 
forward direction. It contains and protects the principal 
organs of circulation and respiration, viz., the heart and its 
membranous bag, the pericardium, the large blood-vessels, 
the lungs invested by the pleurae, and the major part of the 
oesophagus. 

The boundary-lines of the cavity are, roughly speaking, 
the ribs, which surround the thoracic barrel like the hoops of 
a cask, the dorsal vertebrae, the sternum, and the costal car- 
tilages (Fig. i). 

In giving these general outlines, however, it must be con- 
sidered that its upper as well as lower boundary-lines are not 
in exact proportion with the osseous thorax, since the upper 
overlap the sternal end of the first rib and clavicle and also 
extend beyond the first dorsal vertebra. 

Similar conditions exist at the lower boundary-lines, where 
the diaphragm represents the line of division between the 
thoracic and the abdominal cavity. A portion of this organ 
extends high up into the osseous thorax, so that a considerable 
part of the thoracic wall also covers abdominal organs. 



2 Anatomy of Thoracic Wall and Diaphragm. 

The transverse diameter of the thoracic cavity is widest 
along the attachment of the diaphragm. The boundary-lines 
are the ensiform process in front, the lower two ribs, the anterior 
parts of the false ribs, and the common costal cartilage, which 




Floating ribs 
Fig. i. — The Thorax, Front View. — (Morris' "Anatomy.") 

connects these ribs with the sternum, on the side, and the 
twelfth dorsal vertebra behind. 

The exterior aspect of the chest measures, according to 
the perimetric observations of Wintrich, 89.52 centimetres at 



Perimetric Figures. 3 

the highest point in the axilla, 86.64 on a level with the mammilla, 
and' '81.88 at the junction of the ensiform process with the 
sternal body. These figures comprise the average condition 




Fig. 



-Six-months-old Embryo Skiagraphed through Amnion, Showing 
Thoracic Relations. 



found in men of twenty-five years. Perimetric figures, gained 
from the thorax of women of twenty-five years, show Si. 90 



4 Anatomy of Thoracic Wall and Diaphragm. 

centimetres at the highest point of the axilla, 81.00 in the 
middle, and 78.00 below. 

The embryonic thorax and that of new-born children (Fig. 
2) show a marked difference, the lungs especially being but 
little distended at the early period of life while the liver is ex- 
tumely large (Fig. 3). This explains the projection of the 




Fig. 3. — Thorax of New-born Child, Skiagraphed. 

lower thoracic sphere at that age (Fig. 4). The average trans- 
verse diameter of the thorax in men amounts to 28 centime- 
tres on a level with the eighth rib, the sagittal on a level with 
the base of the ensiform process 20, and the vertical 35.5 at 
the posterior and 15.5 at the anterior wall. In women the 
posterior vertical diameter is, on the average, about 2 centi- 
metres less. The normal female chest is more round-shaped 



Thoracic Landmarks. 5 

than the male, but has a smaller general capacity. Its ster- 
num is somewhat shorter, the proportion of its superior open- 
ing being larger. It may also be said that the upper ribs are 
more movable in the female, an important circumstance which 
permits of easier respiration during pregnancy. 

For proper localization the following landmarks should 
be borne in mind: 

The median line, alongside the middle of the sternum. 

The sternal lines, alongside the lateral margins of the 
sternum. 



& 



M 










Fig. 4. — The Thorax at the Eighth Month. — (Morris' "Anatomy.") 
(On the left side eight cartilages reach the sternum.) 

The mammillary or papillary lines, through the nipples. 

The parasternal lines, in the middle between the sternal 
and mammillary lines. 

The axillary lines, dropped from the middle of the axilla. 
Clinically an anterior and a posterior axillary line is distin- 
guished, the anterior extending from the lower margin of the 
pectoralis major muscle, the posterior beginning at the lower 
margin of the latissimus dorsi. 

The scapular lines, which begin at the lower angles of the 
scapulae. 



6 Anatomy of Thoracic Wall and Diaphragm. 

The sterno-costal lines, which follow an oblique direction 
and extend from the sterno-clavicular junction to the tip of the 
eleventh rib. 

The exterior aspect of the thorax is best divided into an 
anterior region (sternal), two lateral (costal) regions, and a 
posterior (spinal) region. 



STERNAL REGION. 
The sternal region is bounded by the jugular fossa above 
and the ensiform process below, in the parasternal lines, two 
inches from the sternal margin, laterally. The tissues under- 
neath the integument are represented by their connective 
tissue, which connects the skin with the sternal periosteum 
in front and the sterno-costal ligament at the sides. 

The Sternum. 

The sternum (os or scutum pectoris, os xiphoides, ari t 0o<;, 
by Hippokrates — hence the term " stethoscope"), a flat and 
narrow bone, is situated in the median line of the anterior 
portion of the thorax, directly opposite the spinal column. 
Its peculiar shape recalls the short ancient sword of the Romans, 
which justifies its division into handle, blade, and point (Figs. 
5 and 6). 

The handle (manubrium), which has a triangular shape, 
represents the upper and broadest portion. It is somewhat 
nearer the spinal column than the lower, sternal end. Its 
anterior surface is slightly convex, while the posterior is con- 
cave. The superior margin of the manubrium, which is the 
thickest, shows the pre-sternal notch at its centre and an oval 
articular surface on each side. The inferior margin is 
straight, the thin layer of cartilage covering its rough surface 
articulating with the upper portion of the blade. On each 
side of the pre-sternal notch a saddle-shaped articular surface 



Clavicular notch 



For first costal 
cartilage 



Xiphoid foramen 



The Sternum. 

Interclavicular notch 




Sterno-mastoid 



Pectoralis major 



Rectus abdominis 



Xiphoid or metasternum 

Fig. 5. — The Sternum, Anterior View. — (Morris' "Anatomy.") 



8 Anatomy of Thoracic Wall and Diaphragm. 



Clavicular notch 
Sternohyoid 

Sterno-thyroid 



Triangularis sterni 




For first costal cartilage 



Diaphragm 

Fig. 6. — The Sternum, Posterior View. — {Morris' "Anatomy.") 



Sternal Blade. g 

serves for purposes of articulation with the sternal end of the 
clavicle. 

The lateral margins slightly converge toward the blade 
and continue in it. 

The blade (syn., meso-sternum, body, gladiolus) is three 
times as long as the manubrium, but much thinner and nar- 



Single centre for 
manubrium ~^r~ 
sterni ^ifc 



Single centre for i 
each of the four ' 
pieces of the 
gladiolus 



Single centre for / 

ensiform process \y 




_ Centre for man- 
ubrium sterni 



Accessory centre 



Single centre for 
first piece of 
gladiolus 



Bilateral centres 
for second, 
third, and 
fourth pieces 
of gladiolus 



Single centre for 
ensiform process 



Fig. 7. — Ossification of the Sternum. — {Morris' "Anatomy") 

A, Common arrangement of the ossific centers. B, Showing accessory centre in the 
manubrium sterni, and bilateral centres in the second, third, and fourth pieces of 
the body. 



rower. Its anterior surface shows three transverse lines 
which cross it opposite the third, fourth, and fifth articulation- 
surfaces. They are the indications of the union of the four 
separate osseous nuclei during the era of development (Fig. 7). 
The slightly concave posterior surface also presents these 
three lines, but less distinctlv. 



io Anatomy of Thoracic Wall and Diaphragm. 

The superior margin has an oval surface with which the 
manubrium articulates. The narrow inferior surface artic- 
ulates with the xiphoid process. 

The point (syn., meta-sternum, processus xiphoideus or 
ensiformis or mucronatus) is much smaller and thinner than 
the other pieces of the sternum. During the stage of develop- 
ment it remains cartilaginous throughout and only becomes 
ossified in adults. Its upper margin articulates with the 
lower end of the sternal body, while its lower end furnishes the 
attachment for the linea alba. The end is generally sharply 
pointed, but sometimes it is also found broad or bifurcated, 
and in rare cases perforated. 

The lateral borders of the sternum articulate with the 
inner ends of seven costal cartilages. 

The synchondrosis between manubrium and gladiolus 
does not ossify before early manhood, while in infants, espe- 
cially if there be disturbances of respiration, as in pertussis or 
in narrow-chested children, it may be extremely movable. 
The connection of the sternum with the elastic cartilages of the 
true ribs permits so large a degree of flexibility that even a 
great amount of violence exerted upon it from before is not 
apt to fracture it. If the sternum is insufficiently developed a 
hiatus forms, through which the heart may protrude from 
the thoracic cavity (ectopia cordis). 

THE RIBS. 

The ribs (costae), which are twelve in number on either 
side, represent elastic osseous arches which extend from the 
spinal column to the sternum. 

Each rib consists of an osseous portion and its cartilag- 
inous continuation, which is termed the costal end. If a 
cartilaginous portion of a rib reaches the lateral border of the 
sternum, we speak of it as a true rib (costa vera or genuina), the 
upper seven being true ribs. If the costal cartilage does not 



The Ribs. n 

reach the sternum, as is the case with the live lower ribs, 
then we term them false ribs (costa spuria or mendosa). 
The cartilages of the first three false ribs are attached to the 
cartilage of the rib above, while the two lower have a loose, 
free end in front, wherefore they are called floating ribs 
(costae fluctuantes) (Fig. i). 

Each rib, the first excepted, shows an external surface 
which is convex and an internal which is concave. There is 
also an upper border which is slightly round-shaped and a lower 
one. The interior surface of the inferior border contains a 
deep groove (sulcus costalis) which runs parallel to the border, 
and lodges the intercostal nerve and vessels (Fig. 8). 

There are two extremities, viz., a sternal and a vertebral. 
The intervening part is called the shaft (body). 

At the vertebral extremity head, neck, and tuberosity 
must be distinguished, the head showing an articular surface of 
renal shape, which is divided into two articular facets by a hori- 
zontal projection (Fig. 8). The neck represents the flattened 
part, which forms the direct continuation of the head and is one 
inch in length in the adult. Its situation is right in front of 
the transverse process of the inferior of those two vertebras 
which serve as the articulation with the head. Near the 
lower margin and on its posterior surface a slight prominence, 
called the tubercle or the tuberosity, presents itself. The 
inferior half of the tuberosity is provided with a small articu- 
lar surface for the extremity of the transverse process of the 
inferior of the two vertebrae which articulate with the head. 
The other half presents a rough eminence to which the poste- 
rior costo-transverse ligament attaches itself. 

The body is flat and thin. Its smooth and convex external 
surface is characterized by an oblique eminence, termed the 
angle, to which a tendon of the ilio-costal muscle attaches 
itself. Here the rib is slightly bent in two different directions. 
The distance between the tuberosity of the neck and this ans^le 



[ 2 Anatomy of Thoracic Wall and Diaphragm. 



Subcostal 
groove 




Sternal end for costal cartilage 



Fig. 8. — The Seventh Rib of the Left Side, Seen from Below. — (Morris' 
"Anatomy.") 



Costal Body. 



13 



gradually becomes longer from the second rib on to the tenth. 
The rib-portion intervening between the tuberosity and the 
sternal extremity is twisted on its own axis. Near the sternal 
portion it is also marked by an oblique line, termed the anterior 
costal angle. As to the sulcus costalis, see above. 

The flattened sternal end of the shaft shows an oval-shaped, 
concave articular surface for the reception of the costal carti- 




Single facet (some- 
times two facets 
are present) 



Single facet (this rib 
has an angle, but 
no tuberosity and 
no neck) 



Single facet (this rib 
has neither tuber- 
osity, angle, nor 
neck) 



Fig. 9. — The Vertebral Ends of Tenth, Eleventh, and Twelfth Ribs. — (Morris' 
"Anatomy.") 

lage. All ribs are similar to each other, but they vary in 
their length, in the degree of their curvature, the direction, 
the relations of the body to the neck (see above) and the 
relation of the costal cartilages to each other. 

The length of the ribs gradually increases from the first 
to the eighth and decreases in the same way from there to the 
twelfth, the latter being shorter than the first. As far as the 
direction is concerned, it is observed that the superior ribs 



i 4 Anatomy of Thoracic Wall and Diaphragm. 



are less oblique than those further down, the highest degree of 
obliquity being attained at the ninth. The length of the 
costal cartilages corresponds with that of the various ribs. 
Their shape appears more flattened at the upper ten, while 
the eleventh and twelfth are round-shaped (Fig. 9). The 
direction of the three upper cartilages is nearly horizontal, 




Levator costae 

Accessorius 
(insertion) 

Cervicalis ascen- 
dens (origin) 

Serratus posticus 
superior (in- 
sertion) 
Scalenus posticus 



Third digitation 
of serratus 
magnus 



Fig. 10. — First and Second Ribs. — {Morris'' "Anatomy") 

while those below, in contrast to the ribs, ascend obliquely 
toward the sternum. 

The relations of the ribs among themselves are such that 
they leave a space between each other. This is termed the 
intercostal space (spatium interosseum) . 

As to the peculiarities of some ribs, it may be said that the 



Tuberculum Lisfranci. 



15 



first rib, which is the shortest and most curved of all, is flat 
and very broad and shows a most important tuberosity at its 
superior surface near its inner margin, which separates two 
shallow grooves (Fig. 10). The anterior groove is for trans- 
mitting the subclavian vein, while the posterior is for the cor- 



Epiphysis for the head. Appears at 
fifteen; fuses at twenty-three 



Epiphysis for tubercle. Appears at 
fifteen; fuses at twenty- three 



The cartilaginous shaft com- 
mences to ossify at the eighth 
week of intrauterine life 




Fig. 11. — Rib at Puberty. — {Morris' "Anatomy.") 

responding artery. The tuberosity, called the scalene tubercle 
or tuberculum Lisfranci, serves as a valuable landmark in 
the surgery of the region. 

As to the stage of ossification, it may be said that the first 
ten ribs show three nuclei at the early period of life, one repre- 
senting the head, another the shaft, and the third the tubercle. 



16 Anatomy of Thoracic Wall and Diaphragm. 

The eleventh and twelfth show no tubercle-centre. Ossifi- 
cation of the shaft begins at the eighth week of intrauterine 
life, while that of head and tubercle appears between the 
sixteenth and twentieth years (Fig. 1 1). 

The number of ribs may be increased by the presence of a 
supernumerary one, either at the lumbar or at the cervical 
ends of the series. While the lumbar variety, which seldom 
reaches considerable size, is of little surgical importance, the 
cervical type demands the most thorough consideration. (See 
Figs. 39, 40, and 41). 

The movements of the ribs are different in proportion to 



(M/ c 




Fig. 12. — Diagram of Axis of Rib-mo vemext, which is Likened to the Move- 
ment of a Pump Handle (a, b). — (Morris, after Kirkes.) 

their different shapes. The extremities of the first few ribs 
move up and down, the costal heads and tubercles acting like 
hinges. The bodies and angles of the ribs below rise as high 
as the extremities, the tubercles moving up and back during 
the act of inspiration (Fig. 12). 



THE THORACIC OR DORSAL VERTEBRA. 

The fundament of the trunk is formed by the spinal column 

(rhachis), which is composed of a series of thirty-five bones 

termed spondyli or vertebrae. Seven belong to the cervical, 

twelve to the dorsal, five to the lumbar, five to the sacral, and 



Vertebral Processes. 



17 



Cervical 
vertebra 




Costal process 



Transverse process 



Neuro-central suture 
Cervical rib 




Transverse process 
Costo-transverse 
foramen 

Neuro-central suture 
Rib 



Transverse process 
Lumbar rib 



Neuro-central suture 
Costal process 



Fig. 13. — Morphology of the Transverse and Articular Processes. — (Morris* 
3 " Anatomy.") 



18 Anatomy of Thoracic Wall and Diaphragm. 

four to the coccygeal region, the latter simply figuring as an 
appendage. 

All vertebrae consist of two characteristic portions, a body 
in front and an arch behind. Two pedicles and two laminae 
form the latter and support seven processes altogether, namely, 
a spinous, two transverse, and four articular. 

While the vertebrae of the various series differ more or less, 
the most essential parts are constructed on a common plan. 
As to their previous mode of development see Figs, n and 13. 
The dorsal vertebra, in which we are especially interested, 
being the paradigm for the others, we will confine ourselves 
to the description of this special type of bone (Figs. 14 and 15). 

The dorsal vertebrae, larger than the cervical and smaller 
than the lumbar, are the carriers of the ribs and therefore pro- 
vided with small cartilaginous surfaces for articulation with 
the costal heads at the side of their bodies. The heart-shaped 
bodies are like those of the cervical and lumbar series, in 
general, but differ inasmuch as they are much thicker ante- 
riorly than posteriorly, where they are concave, while their front 
shows a convexity. At each side two cartilaginous demi- 
facets, an upper and a lower one, present themselves near the 
pedicles. As mentioned above, they serve the purpose of 
receiving the heads of the ribs. 

The pedicles consist of two short and constricted osseous 
columns, the concavities of which are termed vertebral notches. 
They are four in number. By the contact of two vertebrae 
their notches form the intervertebral foramina, which permit 
of communication with the spinal canal and transmit the 
spinal nerves as well as the blood-vessels. 

The laminae consist of two broad osseous plates which 
enclose the small circular spinal foramen. By overlapping 
each other they appear like assorted tiles on a roof. Their 
connection with the body is effected by the pedicles. 

The long and triangular spinous process projects back- 



Transverse Processes. 



19 



ward and downward from the point of union of the laminae 
and ends in a slight tubercle. One process overlaps the other. 



Demi-facet for head of rib 



Superior articular process 
Pedicle 



Facet for tubercle of rib 
Transverse process 




■ Spinous process 

Fig. 14. — A Thoracic Vertebra, Side View. — {Morris' "Anatomy.") 

■ Spinous process 



Pedicle 
Demi-facet for head of rib 



Transverse process 




Fig. 15. — A Thoracic Vertebra. — (Morris' "Anatomy.") 

The two transverse processes are long, thick, and mas- 
sive, and extend obliquely backward and outward from the 



20 Anatomy of Thoracic Wall and Diaphragm. 

arch at the point of union between the pedicles and the laminae. 
They end in a clubbed extremity which contains an oval 
facet for the corresponding articulation-surface of a rib-tubercle. 

The flat articular processes are four in number. They 
spring from the superior and the inferior part of the pedicles. 
The direction of the two superior processes is posterior and 
slightly exterior, while that of the inferior is anterior and 
slightly interior. 

The first dorsal vertebra resembles the seventh cervical 
very closely, its greatest diameter being transverse and its 
lateral margins showing two prominent lips. At each side of 
its body it presents an articular facet for the reception of 
the head of the first rib and a half facet for the superior half 
of the second. The ninth dorsal vertebra is characterized 
by the absence of the demi-facet below, while above it shows 
well-developed semi-facets. The tenth dorsal vertebra has 
an entire facet at each side of its upper border and lacks the 
demi-facets below. 

Both the eleventh and twelfth dorsal vertebrae resemble 
the lumbar, the articular facets for the costal heads being of 
very large size. The pedicles on which the facets are chiefly 
placed are so much stronger and thicker in accordance. The 
twelfth dorsal vertebra distinguishes itself by its very short 
transverse processes and the presence of three elevations, 
viz., the external, superior, and inferior tubercles, corre- 
sponding to the transverse, mammillary, and accessory processes 
of the lumbar vertebrae (Fig. 16). The vertebral bodies 
consist largely of cancellous tissue. If a section is made 
through the centrum, this tissue appears to be horizontally 
and vertically arranged (Fig. 17). 

Among all the bones of the body the spinal column shows 
the first signs of ossification in embryonic life. 

There are three primary and five secondary ossification 
centres at the early period of development, the primary ones 



Peculiarities of Dorsal Vertebrae. 



An entire facet above; a 
demi-facet below. In 
shape the body resem- 
bles that of a cervical 
vertebra 



Usually a demi-facet 
above (sometimes it 
has a demi-facet below) 



Usually an entire facet 
above. Occasionally 
this facet has been in- 
complete. The facet 
on the transverse proc- 
ess is usually small 



An entire facet above. 
None on transverse 
process, which is small . 
This is the anti-clinal 
vertebra 



An entire facet above; no 
facet on transverse 
process, which is trip- 
artite; centrum |large. 
Inferior articular proc- 
esses turn outwards as 
in a lumbar vertebra 




Fig. 16. — Peculiar Thoracic Vertebra. — {Morris' "Anatomy") 



22 Anatomy of Thoracic Wall and Diaphragm. 




Fig. 17. — A Vertebral Centrum in Section to Show the Pressure Curves. — 
(Morris' "Anatomy.") 

forming as early as the seventh week of embryonic life. The 
nuclei of the bodies divide early and may remain bilobed during 
lifetime (Fig. 18). 




Fig. 18. — A Divided Thoracic Vertebra. — (Morris, after Turner.) 

At the time of birth there are three bone-pieces, viz., a 
body and two side pieces, which are connected by hyaline 
cartilage (Fig. 19). 




Lateral mass 



Neuro-central suture 
Centrum or body 



Fig. 19. — A Vertebra at Birth. — (Morris' "Anatomy.") 



Relations of Sternum. 



2 3 



Anterior 
chondro- 
sternal 
ligament 




An interarticular 
ligament 



The plate of fibro- 
cartilage between 
manubrium and 
meso-sternum 



Fourth rib ^^ 



Fifth rib "?££ 



Interchondral 
capsular ligament 

Fig. 20. — The Sternum. — (Morris' "Anatomy") 

(Left side, showing ligaments; right side, the synovial cavities.) 



24 Anatomy of Thoracic Wall and Diaphragm. 



LIGAMENTOUS CONNECTIONS OF THE THORACIC 
BONES. 

The connections of the ribs are to be divided into those 
which are formed by the true ribs and into those of the false. 
The true ribs connect with the spinal column at their posterior 
extremities, while at their anterior ends they attach them- 
selves to the lateral margins of the sternum by their cartilages. 
Both connections form the articulations which are known as 
costo-sternal and costo-spinal articulations. 




Fig. 21. — Anterior View of Sterno-costo-clavicular Joint. — (Morris 7 

"Anatomy.") 

(The capsule is cut into on the left to show the interarticular fibro-cartilage dividing the 

joint into two cavities.) 

The costo-sternal articulations (Fig. 20) are of the 
arthrodial type and include the ribs from the second to the 
seventh. The first costal cartilage attaches itself to the ster- 
num without forming a joint, the union therefore being of the 
synarthrodial character. In rare cases, however, a true 
articulation between the first costal cartilage and the manu- 
brium sterni is observed (Figs. 21 and 22). With the growing 
popularity of the Rontgen rays, it may be found that this 
condition is a frequent one. 



Joints of Costal Cartilages. 25 

The joint of each costal cartilage consists of a synovial 



Sternohyoid Sternothyroid 




Fig. 22. — Posterior Surface of the Manubrium (Pre-sternum), with Sternal 
Ends of Clavicles and the First Costal Cartilages. — {Morris' "Anatomy") 

capsule, which is strengthened by ligamentous fibres called 
interchondral ligaments, internally as well as externally. 



The interarticular 
fibro-cartilage 



The joint between 
the sternum and 
second costal 
cartilage 




Fig. 23. — Section through Sternoclavicular Joint. — {Morris' "Anatomy") 

The joint formed by the second costal cartilage and the 



26 Anatomy of Thoracic Wall and Diaphragm. 

sternum frequently contains a fibrous cartilage, which must 
be regarded as a continuation of the cartilage situated between 
the gladiolus and the manubrium of the sternum. This 
cartilage, by traversing the joint horizontally, divides the 
joint-cavity into two separate spaces (Fig. 23). Of the other 
ligaments, the ligamentum costo-xiphoideum, which springs 




The interarticular 
ligament 



The superior or ante- 
rior costo-transverse 
ligaments 

The stellate ligament 



Fig. 24. — Showing the Anterior Common Ligament of the Spine, and the Con- 
nection of the Ribs with the Vertebrae. — (Morris' "Anatomy.") 



from the sixth and seventh costal cartilages and attaches itself 
to the xiphoid process, is notable. 

As evident from the description of the vertebrae, the costo- 
spinal articulations, that is, the joints between them and 
the posterior extremities of the ribs, are double for the first 
ten ribs, wherefore they are properly divided into costo- 
central (costo-vertebrales), that is, those which are formed 



Costo-central Articulations. 



27 



between the costal heads and the vertebral bodies, and into 
costo -transverse (costo-transversales), that is, those which are 
between the neck and tubercles of the ribs and the transverse 
processes (Fig. 24). 

The costo-central articulations are arthrodial in type 
and consist of a capsule, which contains bundles of ligamen- 
tous fibres (anterior costo-vertebral, or stellate ligament, or 
ligamentum capituli costae anterius or radiatum) (Fig. 25). 



Anterior costo- 
central or stel- 
late ligament 

Costo-central 
synovial sac 




Costo-transverse synovial sac 



Posterior costo-transverse ligament 



Fig. 25. — Horizontal Section through the Intervertebral Disc and Ribs- 

(Morris' "Anatomy") 



These fibres radiate from the anterior portion of the costal 
head. The interiors of the first ten joints contain the ligamen- 
tum trans versum capituli costse, which springs from the crests of 
their heads, to be attached to the corresponding intervertebral 
discs. This ligament is absent at the last two ribs and also 
at the head of the first whenever the groove for the head is 
formed by the first dorsal vertebra alone, the seventh cervical 
vertebra not participating. The structure of this ligament 
is fibro-cartilaginous. 



28 Anatomy of Thoracic Wall and Diaphragm. 

The costo-transverse ligaments (Fig. 26) consist of a thin 
capsule which is supported by a strong fibrous band, called the 
ligamentum costo-transversale posterius, which covers the pos- 
terior region of the joint. The costo-transverse articulations 
permit of slight physiological displacement of the ribs, as 
necessitated by their excursions during respiration. The 
transverse processes of the vertebrae prevent any backward 
deviation of the ribs during that process. It is evident that 
the eleventh and twelfth ribs, on account of their small size 



Spinous process of 
seventh cervical 
vertebra 



Capsular ligament of the first costo- 
transverse joint 




Capsular ligament of 
first costo-central 
joint 



Fig. 26. — The Capsular Ligaments of the Costo-vertebral Joints. — (Morris' 
"Anatomy.") 

and deep situation, are so well protected against dislocation 
that they do not need any protection by transverse processes. 
The anterior and posterior ligamenta colli costaa also secure 
the position while elevated during the act of inspiration. 



INTERCHONDRAL ARTICULATIONS. 

The articulations of the costal cartilages with each other 

take place in such a manner that the margins of the sixth, 

seventh, and eighth, sometimes also of the ninth and tenth, 

unite with each other by small oblong facets. A thin capsular 



Muscles and Vessels of Sternal Region. 29 

ligament lined by a synovial membrane, and supported by 
interchondral ligaments passing from one cartilage to the 
other, encloses them. 



COSTO-CHONDRAL ARTICULATIONS. 
The ends of the costal cartilages articulate with a cup- 
shaped depression at the costal extremities, firm union being 
effected by the periosteum. 



ARTICULATIONS OF THE COSTAL CARTILAGES WITH 
THE STERNUM. 

The joints formed between the cartilages of the true ribs 
and the sternum are, excepting the first, of the arthrodial 
type. As mentioned above, the first joint has a synarthrodial 
character, since its union with the sternum is a direct one. 



MUSCLES, VESSELS, AND NERVES. 

Sternal Region. 

The muscles of the sternal region are the pectoralis major 
with its sterno-costal origin, the median portion of the internal 
intercostales muscles behind the pectoralis major, and the 
triangular sternal muscle at the posterior side of the sternum. 

The artery of the sternal region is the internal mammary, 
which arises from the anterior and lower part of the subcla- 
vian, where the latter is opposite the vertebral, passing behind 
the clavicle and the vena anonyma and then descending along- 
side the posterior surface of the costal cartilages, parallel 
with the sternal margin. 

From the internal mammary the arteriae thymicae, medias- 
tinals anteriores, and pericardiaco-phrenicae branch off to the 
thoracic cavity, while the rami perforantes, the intercostales 



30 Anatomy of Thoracic Wall and Diaphragm. 

anteriores, and the rami sternales go to the chest wall. The 
internal mammary terminates in the sixth intercostal by 
dividing into the superior epigastric and the musculo-phrenic 
arteries. 



Phrenic nerve 

Subclavian artery 

Subclavian vein, cut 



Anterior intercostal branch 



Anterior intercostal branch 



Musculo-phrenic artery 




Common carotid artery 
Internal jugular vein 

Subclavian vein, cut 
Scalenus anticus muscle 

Sternum 

Triangularis sterni muscle 
Perforating branch 



Superior epigastric artery 



Deep epigastric artery 



Deep circumflex iliac artery 



Fig. 27. — Scheme of the Right Internal Mammary Artery. — {Morris, after 
Walsham.) 



The veins of the sternal region are divided into subcu- 
taneous and deep. The subcutaneous veins form a large net 
on the anterior fascia of the pectoralis major muscle, which 



Muscles of Costal Region. 31 

communicates with the external jugular veins above, and the 
inferior subcutaneous epigastric veins below. Lateral anas- 
tomoses are formed with the axillary veins. 

The deeper veins are formed from the internal mammary 
vein and its branches. 

The lymph -vessels correspond with the sphere of the 
branches of the internal mammary artery. The nerves of 
the sternal region are represented by the anterior thoracic 
and the termini of the intercostal nerves. The latter supply 
the internal intercostal muscles as the triangularis sterni. 

Costal Region. 

The costal region is bounded by the parasternal line in 
front, the scapular lines behind, the first rib above, and the 
last below. The thin and movable integument of this 
region covers a stratum of loose connective tissue, which is 
interspersed with fat. Its fascia is firmly coherent with the 
superficial muscles. 

The muscles are the serratus anticus major and the in- 
ternal and external intercostal, besides the pectoralis major and 
minor and the subclavius. 

The pectoralis major muscle originates from the anterior 
surface of the inner half of the clavicle, the corresponding half 
of the anterior part of the sternum, the cartilages of the true 
ribs with the occasional exception of the first and seventh, and 
the aponeurosis of the external oblique muscle of the abdomen. 
It inserts itself at the anterior lip of the bicipital groove of 
the humerus. 

The pectoralis minor muscle originates from the outer 
surface as well as the upper border of the third, fourth, and 
fifth ribs close to their cartilaginous portions and from the 
aponeurosis which covers the intercostal muscles. 

The subclavius muscle originates from the cartilage of 
the first rib in front of the li^amentum rhomboideum clavicular 



32 Anatomy of Thoracic Wall and Diaphragm. 

and inserts itself at a groove on the under surface of the 
middle third of the clavicle. 

The musculus serratus anticus major originates by 
nine fleshy digitations from the outer surface and the upper 




Aponeurosis of external oblique 



External intercostal 



Fig. 28. — The Pectoralis Major and Deltoid. — (Morris* "Anatomy") 

border of the eight upper ribs and inserts itself into the anterior 
lip of the posterior scapular border. 

The external intercostal muscles (Fig. 29) are eleven in 
number on each side of the body and extend from the rib- 
tubercles behind to the insertion of the rib-cartilages in front. 



Intercostal Muscles. 



33 



The direction of their fibres is downward and forward. They 
originate from the outer lip of a groove on the lower rib- 
border and are inserted into the upper border of the next rib 
below. 




Fig. 29. — The Intercostal Muscles. — (Morris' "Anatomy.") 



The internal intercostal muscles (Fig. 29) are also eleven 
in number, communicating at the sternum and anterior ex- 
tremities of the false ribs and extending to the costal angle be- 
hind. The direction of their fibres is downward and backward. 
They originate from the cartilages of the false and true ribs 



34 Anatomy of Thoracic Wall and Diaphragm. 

and the inner lips of the groove on the lower border of each 
rib and insert into the upper border of the next rib below. 

The triangularis sterni muscle (Fig. 30) originates from 
the lower part of the sternal side, from the inner surface of the 
ensiform cartilage and the costal cartilages of the four lower true 



Sternohyoid 



Sternothyroid 




Transversalis abdominis 

Fig. 30. — The Muscles Attached to the Back oe the Sternum. — {Morris' 
"Anatomy") 

ribs, and inserts into the lower border and the interior surface 
of the cartilages of the second, third, fourth, and fifth ribs. 

The endothoracic fascia is a thin membrane which is 
attached to the outer side of the parietal pleura. It unites 
the exterior portion of the costal pleura with the interior side 



Arteries of Costal Region. 35 

of the ribs and the intercostal muscles and also adheres to the 
pleural domes, the posterior sternal portion, and the vasa 
mammaria interna. With the phrenic pleura it covers the 
convex part of the diaphragm, thus connecting both organs 
firmly. It ends at the anterior side of the spinal column in 
the loose connective tissue, which surrounds the organs situated 
at the posterior portion of the mediastinal space. 

The arteries of the costal region are the axillary branches ; 
viz., the superior thoracic, the acromial thoracic, the thoracica 
longa (external mammary) and the thoracico-dorsalis, and the 
intercostales anteriores and posteriores and the intercostalis 
suprema. 

The small superior thoracic branches off above the 
upper border of the pectoralis minor muscle and passes 
forward and inward between the pectoral muscles. There 
it is distributed and forms anastomoses with branches of the 
internal mammary and the intercostales of the first and second 
intercostal spaces. 

The large acromial thoracic branch originates from the 
anterior aspect of the axillaries, passes forward on a level 
with the upper margin of the pectoralis minor muscle and 
separates into two sets of diverging branches, that is, one 
losing itself in the thoracic wall and the other outwardly 
toward the acromion. 

The thoracica longa passes alongside the lower margin 
of the pectoralis minor muscle in a forward and inward direc- 
tion until it reaches the mammary gland, wherefore it is also 
called the external mammary. 

The thoracico-dorsalis is a branch of the subscapular 
artery, from which it turns backward to the extent of five 
centimetres from its point of origin. 

The posterior intercostal arteries, nine in number, originate 
directly from the posterior aortic wall. Those of the right 
side pass to the [corresponding intercostal spaces before 



36 Anatomy of Thoracic Wall and Diaphragm. 

the bodies of the dorsal vertebrae, behind the oesophagus, the 
thoracic duct, the vena azygos, and the termini of the sym- 
pathicus. Those on the left side, which are somewhat 
shorter, pass behind the sympathicus and the vena hemiazygos. 
After having entered the intercostal space a small dorsal 
ramus branches off, which by its ramus spiralis communicates 



Scalenus anticus muscle 

Deep cervical branch 

First dorsal nerve 

First intercostal nerve 
Subclavian artery 

'Second intercostal nerve 



Inferior cervical 
ganglion 



Superior intercostal 
artery 



Arteria aberrans 




Anterior inter- 
costal artery 
Third intercostal 
nerve 



Arteria aberrans 



First aortic inter- 
costal artery 



Second aortic in- 
tercostal artery 



Intercostal ves- 
sels of third space 



Intercostal vessels of fourth space 



Fig. 31. — Scheme of the Right Superior Intercostal Artery. — (Morris, after 
Walsham.) 



with the spinal cord. After having given off the ramus 
dorsalis, the intercostalis passes forward alongside the inter- 
costal space between the external intercostal muscles and the 
parietal pleura and finally anastomoses with the anterior inter- 
costal arteries of the internal mammary. 

The superior intercostal artery (Fig. 31) arises from the 



Superior Intercostal Artery. 



37 



posterior part of the subclavia near its lower border and close 
to the inner margin of the musculus scalenus anticus. In its 
course, which at first is backward, it gives off the arteria pro- 
funda cervicis, which anastomoses with the arteria prin- 
ceps cervicis, thus establishing an important collateral connec- 



Longissimus dorsi 



Internal division of muscular branch 
Semispinalis dorsi and multifidus spinae 



Retroneural branch 

Medullary branch 

Prenearal branch 

Spinal cord 

Anterior spinal 

artery 



External division of muscular branch 
Ilio-costalis 
f 

Spinal branch 



Intercostal artery 



Vena azygos minor 



Vena azygos major 
Thoracic duct 



(Esophagus 



Anterior intercostal 



Internal mammary artery - 

Anterior perforating 

branch of internal 

mammary artery 




Sympathetic 



Upper or main 
branch of aortic 
intercostal 

Lateral cutane- 
ous branch 



Lowerbranch of 
anterior inter- 
costal 

Mammary glan- 
dular branch 

Upper or main 
branch of ante- 
rior intercostal 



Fig. 32. — Scheme of Intercostal Artery. — {Morris, after Walsham.) 



tion. The artery passes downward and backward, then in front 
of the neck of the first rib, sometimes also of the second, and 
loses itself in the first or second intercostal space. It is well 
to remember that the first dorsal ganglion of the sympathicus 
is situated on the inner side of the artery, just opposite the 
neck of the first rib. The superior intercostal artery sends 



38 Anatomy of Thoracic Wall and Diaphragm. 

off branches to the posterior spinal muscles, to the first or second 
intercostal spaces, and to the spinal cord and its membranes. 



M. pect. major M. medianus 

M. pect. min. 



A. axillaris 
A. trior, acromialis 



R. perf. ant 



M. intercost. ext. 




A. thor. suprema 
A. thor. long. 

X. thor. longus 



A. thor. dorsal. 



R. perforans lat. 



Indentation of M serrat.maj. 



Diaphragm S 



Fig. 33. — Vessels and Nerves of the Left Thoracic Region. — (After Waldeyer.) 

The subcutaneous veins of the costal region anasto- 
mose with the veins of the neck, of the axilla, and of the ab- 
dominal wall. The most important collateral circle is formed 



Veins of Costal Region. 



39 



by the vena thoracico-epigastrica longa tegumentosa, which 
after passing the thoracic side anastomoses either with the vena 
epigastrica inferior subcutanea or directly through the oval 
fossa with the femoral veins. Upward there are anastomoses 
with the axillary veins. 



Pectoralis major 



Brachial 
plexus 



Supraclavicular branch 
of cervical plexus 




Serratus 
magnus 



Fig. 34. — Cutaneous Nerves of the Thorax and Abdomen, viewed from the 
Side. — {After Henle.) 

The deep veins of the lateral thoracic sphere are repre- 
sented by the vence inter co stales posteriores. Each one of these 
veins accompanies an arteria intercostalis posterior, as vena 
comitans. Ten of the venae intercostales posteriores dextrae 
anastomose with the vena azygos. The upper, that is, those 



4o Anatomy of Thoracic Wall and Diaphragm. 

accompanying the arteria intercostalis suprema dextra, anas- 
tomose either with the vena azygos or upward with the vena 
anonyma dextra or the vena cava superior. The four left 
lower veins of the intercostales posteriores unite in one common 
branch, called the vena hemiazygos inferior, which finally 
also anastomose with the vena azygos. The four upper 
unite as the vena hemiazygos superior (accessoria), which com- 
municates with the vena azygos inferior and the vena inter- 
costalis superior sinistra. Anteriorly the venae intercostales 
posteriores anastomose with the branches of the vena mam- 
maria interna down to the sixth rib. Further below, that is, 
from the seventh to the tenth rib, they communicate with 
the vena musculo-phrenica. The last two intercostal veins do 
not have any anterior anastomotic connection. 

The lymphatics of the costal region are also superficial 
and deep-seated, the latter passing through the intercostal 
spaces. 

The nerves (Fig. 34) originate mainly from the thoraco- 
dorsal nerves, only the musculus serratus anticus major being 
supplied by the nervus thoracicus longus from the brachial 
plexus. 

The anatomy of the mammary gland is referred to in the 
chapter on Diseases of the Breast. 



DIAPHRAGM. 

The diaphragm (Fig. 35) represents the dividing septum 
which separates the thoracic from the abdominal cavity. Its 
circumferential attachment being more deeply situated than 
its ventral tendon, its convexity gives it the shape of a dome 
while in a passive state. In order to permit of the passage of 
important organs, it is provided with three large openings. 
These are: (1) the oesophageal, a muscular opening at a level 
with the ninth dorsal vertebra, which permits of the passage 



The Diaphragm. 



41 



of the oesophagus as well as of the pneumogastric nerve. (2) 
The aortic, a tendinous opening which is at a level with the 
twelfth dorsal vertebra and permits of the passage of the 
aorta, the vena azygos, and the thoracic duct. (3) The foramen 
quadratum, also a tendinous opening situated opposite the 
ninth dorsal vertebra, which permits of the passage of the 
vena cava ascendens. 



Sternal origin 



(Esophagus 



Costal origin 



Ligamentum 
arcuatum 
internum 
Left crus 
Ligamentum ar- 
cuatum externum 
Transverse proc- 
ess of second 
lumbar verte- 
bra 
Fourth lumbar 
vertebra 




Quadratus 
lumborum 



Fig. 35. — Diaphragm. — (Morris 7 "Anatomy") 



The diaphragm muscle originates from the ensiform 
cartilage in front, while on the sides it begins at the osseous 
portions of the seven lower ribs and the ligamentum arcuatum 
externum and internum as well as the lumbar vertebras behind. 
Its insertion is at the central tendon of the diaphragm. 

Of the ligamentum arcuatum internum it must be said 
that it represents a tendinous arch which extends over both 



42 Anatomy of Thoracic Wall and Diaphragm. 

psoas major muscles. Its connection is with the bodies of 
the first and second lumbar vertebrae at its inner extremity, 
while the outer is attached to the transverse process. 

The ligamentum arcuatum externum virtually represents 
the thickened upper edge of the anterior lamella of the fascia 
transversalis, which arches across both quadrati lumborum 
muscles. Its attachment is to the transverse process of the 
second lumbar vertebra at its inner extremity and to apex as 
well as the lower edge of the last rib at its outer extremity. 

The anatomy of the intrathoracic organs is dealt with 
in the chapters on their diseases. 



CHAPTER II. 
SURGERY OF THE THORACIC WALL. 

(A) MALFORMATIONS OF THE THORAX. 

Congenital malformations of the thorax are rare. 
Most important among them are the median fissures of the 
sternum (Fig. 36) by arrested growth. Such sternal clefts may 




Fig. 36.— Two Stages in the Formation of the Cartilaginous Sternum.— {Morris, 
after Ruge.) 

be circumscribed, in which case they could have diagnostic 
interest only. The narrow median gaps as well as the inter- 
rupted sternal clefts, which are generally of an oval shape 

43 



44 Surgery of the Thoracic Wall. 

(Fig. 37), may be confounded with injuries as well as diseases 
of the chest. For differentiation the Rontgen method will 
serve as a reliable guide. In cases of total absence of the 
sternum the ribs insert themselves into a broad fibrous band, 
which has the shape of the sternal bone. 

Differentiation is also difficult sometimes in the case of con- 




Fig. 37. — Hiatus in Sternum. 

genital absence of one or more ribs. The defect is usually 
found at the point of insertion on the sternum, a thin band 
generally substituting the rib-portion, which is not strong 
enough to resist the expanding lungs, so that a pulmonal 
hernia (pneumatocele) may develop. 

Ectopic conditions of the lungs may also be the result of in- 
juries, like costal fractures. The defect may be closed by 



Cervical Ribs. 



45 



osteoplastic operation after Vulpius, which consists in bisect- 
ing the rib portions adjacent to the gap, longitudinally, and 
connecting the flaps, after mobilizing them, with the neigh- 
boring ribs (Fig. 38). 

Among the malformations of the chest the cervical ribs 
may also be mentioned here. They are undoubtedly very 
much more frequent than supposed, but before the Rontgen 
era their presence was but rarely detected. 

While the supernumerary ribs of the lumbar vertebrae possess 



of 




Fig. 38. — Vulpius' Method of Osteoplastic Operation in Costal Defects. 

an academic interest only, the accessory rib of the cervical 
portion of the spinal column commands practical consideration. 
Literature does not contain a single case in which the lumbar 
rib has caused any discomfort whatsoever. In contrast 
hereto, the observations concerning more or less great dis- 
turbances, which were due to cervical rib, are multiplying 
with each year. Since the Rontgen rays have illuminated 
this region also we may hope for more ample statistics. At 
the same time we can figure on more accurate anatomical 
understanding. 



46 Surgery of the Thoracic Wall. 

To this is added the fact that at the time we can inform 
ourselves of the anatomical success of our operative activity. 
We have learned besides to regard the Rontgen picture as 
our valuable guide in outlining the plan of operation. 

Naturally it was the anatomists w r ho gave us the etiology 
at a period when we did not as yet value the clinical impor- 
tance of cervical rib. As the pioneer in this direction we may 
consider Hunauld. 1 Later Grube was able to demonstrate 
76 cases in 45 bodies and 2 in the living. 

Pilling 2 mentions 129 cases. But these were mostly all ob- 
served in the dead body. 

Grube differentiated the different grades of the anomaly 
according to their several stages of development. On the 
basis of his viewpoint we may divide the different types as 
follows : 

(a) Slight degree: The cervical rib reaches beyond the 
transverse process. 

(b) More advanced: The cervical rib reaches beyond the 
transverse process, either with a free end or touching the 
first rib. 

(c) Almost complete: The connection between the car- 
tilage of the first rib is formed either by means of a distinct 
band or the end of its long body. 

(d) Complete: It has become a true rib and possesses a 
true cartilage, which unites with the cartilage of the first rib. 

In general, we can assume that the cervical rib is double 
in 67 per cent, of all cases and single in only 33 per cent. A 
completely developed cervical rib on both sides is to be regarded 
as rare. One such case is described in the above mentioned 
monograph of Pilling. An additional rib which runs from 
the sixth cervical vertebra is to be regarded as a very rare 
condition. With the exception of the author's case, illustrated 

1 " Sur le nombre des cotes moindres au plus grands qu' a 1' ordinaire," Mem. de 
l'academie royale des sciences de Paris, 1743. 

2 "Ueber die Halsrippen des Menschen," Inauguraldissertation, Rostock, 1894. 



Diagnosis of Cervical Rib. 47 

by Figs. 39, 40, this anomaly was observed twice only in litera- 
ture. 

It is significant for the difficulties of the diagnosis which 
naturally presented themselves before the Rontgen era, that 
by far the most of the reports speak of accidental discovery 
at the autopsy. Consequently if no marked disturbance was 
caused, the possessor of the cervical rib undoubtedly took 
his " special marks of identification" with him, unknown, 
to his grave. 

Although this anomaly is of congenital origin the com- 
plaint does not make itself felt until about the twentieth year, 
a fact which is hard to explain. From most reports we learn 
that by far the greater number of patients had passed the age 
of twenty years — a few had even reached the age of fifty-five 
years. In a number of cases it was possible to refer to trauma 
as a precursor of the complaint, in others the presence of con- 
stitutional diseases, such as anaemia, chlorosis, rheumatism, 
scrofula, or even tuberculosis, was observed. 

Whether the loss of fat causing a diminution of padding 
in these diseases is the reason for the greater manifestation of 
the discomfort, must remain to be seen. At any rate an addi- 
tion of special circumstances, the nature of which is still un- 
known to us, must form an important factor in the maturing 
of the disease besides. It is to be assumed that the tissues 
adapt themselves to the rib during the period of development, 
and that no discomfort arises where a certain amount of 
elasticity or yielding tendency exists. Thus the age of the 
patient as of diagnostic moment is valueless. 

If it seems probable now that the presence of cervical rib, 
when giving no disturbance, remains unnoticed, we would 
expect that if such symptoms should appear, the possibility 
of an anomaly would suggest itself. But such, at least 
before the Rontgen era, was not the case. For in most cases 
one more readily thought of everything else, especially of 
tumors of all kinds, rather than cervical rib. 



48 Surgery of the Thoracic Wall. 

Tilmann, 1 who has gained special credit in the investiga- 
tion of these cases, could collect only 26 cases among the , 
living, and of these one half represent accidental findings. 
There cannot be the least doubt that the actual number of 
cases is by far a much greater one. This will in the future 
have to be proved by the Rontgen fays. 

As the principal symptoms of the anomaly the hump-like 
prominence in the lateral cervical region, the superficial pulsa- 
tion of the subclavian artery, and the appearance of pressure 
symptoms in the brachial plexus are regarded. 

Prickling and lancinating pains in the arm, general loss 
of flesh, and especially atrophy of the muscles supplied by the 
median nerve, numbness and diminished compressive power 
of the hand of the respective side, cold sensations, and further- 
more pains in the neck on stretching it have also been observed. 
At times it goes as far as to form an aneurysm of the subclavian 
artery. 2 

A striking fact is that even after the diagnosis has been 
made it is often attempted to master the trouble by internal 
means. But as soon as the physician becomes familiar with 
the anatomy of the cervical rib he must acknowledge that he 
has to deal with a disturbance placed in the way of the normal 
blood- and nerve-paths which has attained the prowess of a 
foreign body. Thus the treatment for the difficulties arising 
therefrom can only be a mechanical one, i. e., surgical. Mas- 
sage, electricity, hot and cold packing, etc., can only be of 
temporal*} 7 benefit and possess the disadvantage that much 
valuable timejs_wasted. Then the disturbance may become 
permanent. 

A radical cure can be effected only by the removal of the 
cause of pressure, that is, of the rib itself. But it is just as 
unwise to remove a cervical rib which causes no disturbance 

1 "Deutsche Zeitschrift fur Chirurgie," Bd. xli. 

2 Wiltshire: "Lancet," p. 633, London, i860; Boyd: "Internat. Med. Mag.," 1893. 



Removal of Cervical Rib. 49 

as it is to leave one that does until lasting tissue changes 
have been brought about. The operative measure, if timely, 
removes all discomfort at once. 

At times the technic for the removal of the rib is very 
simple. In the majority of cases, however, one encounters 
difficulties, wherefore the operation should only be done by 
an experienced surgeon. The difficulty of the removal is 
magnified by the fact that it is necessary to remove the peri- 
osteum with the rib, for if the much easier sub-periosteal 
removal is undertaken one must expect a recurrence due to 
the regeneration of the bone. 

The field of operation grazes the lower two cervical nerves, 
the upper dorsal nerve, and the lower cervical ganglion of 
the sympathetic. Furthermore it touches upon the large 
vessels and the pleura, the latter being especially thin here and 
very easily wounded. Of course, the adhesions which form 
between the costal and pulmonal pleurae in most of these cases 
give a certain amount of protection against the development 
of a pneumothorax, if an injury had been caused. In a case 
of Planet, 1 it seems to have been impossible to avoid injuring 
the pleura, so that a pneumothorax was caused, but without 
any grave disturbance. 

The extirpation of small rudiments whose ends do not 
reach the subclavian artery, is naturally simple. Where we 
have to deal with a fully developed rib the various steps of 
the operation must be so carried out that the artery is avoided 
from the beginning. 

Some of the operators place their incision along the posterior 
border of the sternomastoid. Others advise a longitudinal in- 
cision between the trapezius and the jugular vein. 

The author finds that a triangular flap-incision, running 
directly downwards along the trapezius and then conducted 
towards the sternum about one inch above the clavicle, fully ex- 

1 "Tumeurs osseuses de cou," These de Paris, 1890. 



5° 



Surgery of the Thoracic Wall. 



poses the field of operation. If the trapezius cannot be suffi- 
ciently retracted with broad retractors a transverse incision 
must be made into the muscle, for next to strict asepsis the 
success of the operation depends upon extensive exposure of 
the field of operation. 

The brachial plexus, which usually runs across the rib, 
must also be pushed aside. The subclavian is best pulled for- 
ward. The scaleni are carefully divided at their point of 
insertion. This is best done by using a Cooper shears and, 




Fig. 39. — Cervical Rib Inserting at First Rib. 

advancing layer by layer, lifting the several muscle fibres with 
the flat of the scissors and using the instrument as one would 
handle a grooved director. By means of the author's ring- 
shaped periosteotome (Fig. 86) the rib is then freed of any small 
muscular appendages. The division can easily be accom- 
plished by means of the author's beak-shaped rib-shears. 
(Fig. 87). Some prefer the Gigli saw. Any remains are 
nipped off with the rongeur forceps. 

Fig. 39 illustrates type c in a small anaemic girl of 
twenty-one years, whose family history did not reveal any 



Symptoms of Cervical Rib. 51 

event of special interest. When she became twenty years of 
age, she sustained a fall, after which she began to suffer with 
pain in the right side of the neck. This was, however, regarded 
and treated as rheumatic. Two months later the pains began 
to extend into the arm and were accompanied by prickling 
and numbness of the ringers. She was then treated by neu- 
rologists until a slight bulging of the right side of the neck and 
a corresponding osseous tumor which could be traced from 
the spinal column to the neighborhood of the sternoclav- 
icular joint was diagnosticated by Dr. J. Heckmann at the 




Fig. 40. — Stump of Cervical Rib. 

German Poliklinik. Pulsation was marked. The presence of 
an accessory cervical rib was confirmed by means of a 
Rontgen plate (Fig. 39) . Now the anterior portion of the rib was 
exposed by means of an incision running along the posterior 
border of the sternomastoid muscle. Both the brachial 
plexus and the subclavian artery were found passing over 
it. After the resection of this portion the plexus as well 
as the artery dropped back into the newly formed cavity. 
As the cause of the pressure had been removed it was 
decided to let the posterior remnant of the rib take care of 
itself. The symptoms of complaint gradually disappeared, 



52 Surgery of the Thoracic Wall. 

but returned with undiminished vehemence three months 
later. When the author examined the patient there he 
could find neither prominence nor pulsation. The pulse 
of the axillary, brachial, and radial arteries, however, was 
diminished in tension. The reaction to electricity of muscles 
and nerves was also diminished. Sensation was normal. 
Patient was extremely anaemic and complained of pains in the 
neck and right arm and of numbness of the fingers. On 
stretching the neck the pains were intensified. The power 
of compression of the right hand was diminished. 

The Rontgen picture — extreme lateral position of head 
during exposure (Fig. 40) — shows on the right side the presence 
of a fair-sized costal stump running from the seventh cervical 
vertebra, while on the left a small rudiment is seen. The sixth 
cervical vertebra shows a rudiment on both sides. 

In view of the vehemence of the symptoms, especially of 
the pains, the author decided to reopen the field of operation for 
the purpose of removing the remainder of the rib. Advancing 
carefully, layer by layer, into the deeper tissues, he neither 
came in contact with the brachial plexus nor with the artery. 
It was rather difficult to separate the muscle from the edges 
of the rib. Most of the separating was done bluntly with 
the aid of the Cooper scissors, using them as a support. The 
extirpated fragment of the rib measured 4 cm. As the previous 
resection had been done subperiosteally, a new formation of 
bone of more than one cm. in length had attached itself to 
the stump of the rib. Hence it becomes evident how necessary 
it is always to remove the periosteum with the rib. The rib, 
on the whole, was narrow, thickened at its vertebral attach- 
ment, and presented a small groove on either side. 

Recovery was uneventful. The symptoms disappeared 
entirely shortly after the operation. Two months later slight 
symptoms of pain made themselves felt in the neck on the 
right side, but these also disappeared after the use of the 



Supernumerary Mammae. 



S3 



galvanic current. (See "The Journal of the American Medical 
Association," June 17, 1905.) 

Fig. 41 shows the complete one-sided type (No. d) in a 
man thirty- three years of age. The discovery was entirely acci- 
dental, the patient never having shown any apparent deform- 
ity or being in any way disturbed. 




Fig. 41. — Cervical Rib. 



Supernumerary mammae are not infrequently observed. 
Their seat varies, some being found in the axilla, on the abdomen, 
the dorsal region, and even as far down as the anterior surface 
of the thigh. They have the structures of the normal gland. 
Small accessory glands are still more frequently present in 
the same various regions. Sometimes the breasts are pro- 
vided with two or three nipples. The mammae as well as 
the nipples are only seldom found to be entirely absent. 

Enlargement of the mammary gland is frequently but 
only temporarily observed in new-born boys and also during 
the period of puberty. Sometimes there is secretion of milk 
in male adults. 



54 



Surgery of the Thoracic Wall. 



In hermaphroditism of the male type the development 
of the mammary gland is marked. Fig. 42 shows a hermaph- 
rodite of the preponderant male type (a) who possesses two 
normal mammary glands (Fig. 42, b). Penis and testicles are 
well developed, at the same time there are the indications of a 
vaginal canal. The author is indebted to Dr. J. H. Branth 
for this rare case. 

Spina bifida dorsalis is another important malformation 





. 


X 


mm -* 1 




W^ 1 



Fig. 42. — Man Showing Mammae. 

(Fig. 43). It is rare, while the lumbar type is very frequent. 
The dorsal variety differs from the lumbar variety inasmuch 
as the cord cannot protrude into the hernial sac. 

As regards treatment, it may be said that in the simple 
form of meningocele, which is characterized by a cystic 
distention of the membranes only, the cord itself not partici- 
pating, aspiration followed by the repeated injection of a 10 
per cent, emulsion of iodoform-glycerin generally suffices 



Dorsal Meningocele. 55 

for a cure. In myelocele, where the cord either partially or 
in its entirety enters the sac, or in myelocystocele, where there 
is a cystic distention of the membranes besides, extirpation of 
the sac should be tried. The operation must be of an explor- 
atory character, the membranes first to be opened from the side, 
so that the direction and condition of the nerves may be ascer- 
tained first. After reposition of the cord the cleft may be 
closed by reverting the surrounding periosteum, and protecting 
it by a thick layer of muscle and fascia. In the major- 
ity of these cases the prognosis is unfavorable. Secondary 
deformities of the thoracic cage may be produced by primary 
changes of the spinal column. 




Fig. 43. — Dorsal Meningocele. 

Kyphosis (Fig. 44), by shortening the vertebral column, 
naturally shortens the thoracic cavity while its sagittal diam- 
eter is made longer. It is often combined with the 
loss of the lumbar concavity, so that the vertebral spine is 
arched backward. Sometimes this condition is compensated 
somewhat by lumbar lordosis (Fig. 45). 

Kyphosis is usually produced by defective growth, rhachitis 
being a predominant causal factor. Occasionally a continuous 
habit of stooping may induce it. It may also result from frac- 
tures, osteo-arthritis, acromegaly, Pott's disease and similar 
ailments. 



56 Surgery of the Thoracic Wall. 




Fig. 44. — Kyphosis. 



Kyphosis and Lordosis. 



57 




Fig. 45. — Kyphosis of Upper Dorsum with Compensating Lumbar Lordosis. 



58 



Surgery of the Thoracic Wall. 



Scoliosis (Fig. 46) causes inflection of the thorax by lat- 
eral curvature of the spine associated with rotation of the ver- 
tebrae. Sometimes it is congenital, but in the great majority 
of cases it is of a rhachitic nature and begins at an early period 




Fig. 46. — Scoliosis. 



of life. The essential points of treatment are the plaster-of- 
Paris corset, applied while the patient is suspended in a Sayre's 
apparatus (Fig. 47); later in restoring the power of the 



Plaster Jacket for Kyphosis. 



59 




Fig. 47. — Plaster Jacket Applied in Extension. 
Note folded towel at the epigastrium, which is to be removed after completion of dressing. 



6o 



Surgery of the Thoracic Wall. 



dorsal muscles by massage and electricity and by such exercises 
as produce extension of the back (crawling on the floor). 

The deformity called pectus carinatum (Fig. 48) is also 
caused by rhachitis. It is characterized by a keel-like pro- 
trusion of the sternum while the ribs are collapsed, the lateral 
thoracic portions being inverted. Thus the sagittal diameter 
of the thoracic cavity is diminished. The essential part of 
treatment is that of the rhachitis. At the same time the 
patients should be kept in the recumbent position as long as 
possible. 




Fig. 48. — Pectus Carinatum in a Boy oe Fourteen Years. 



Protrusion of the lower rib cartilages, as a rule, on the 
left side, is especially found in the female. 

Deformities of the ribs often follow curvatures of the 
vertebral column and may sometimes be corrected by rib- 
resection. The author has performed this operation once 
with a fair result, but in two cases there was considerable 
disappointment. 

Extreme flatness of the exterior chest-wall is especially 
observed in girls. Resection of the chest-wall may make it 
collapse so far that it assumes the shape of a funnel. In rare 
cases careful physical exercise should be advised at an early 
period, the same as in chicken-breast. 



Non-penetrating Injuries of Thoracic Wall. 61 

(B) INJURIES OF THE THORACIC WALL (NON- 
PENETRATING). 

The wounds of the thoracic wall (also the gunshot wounds) 
are usually of little significance, except the arteria mammaria 
interna or one of the intercostals be injured. Contusions 
of the throat are produced by external violence and may be 
accompanied by fractures of the ribs, and consequently by 
the injury of the intrathoracic organs, viz., the heart, the lungs, 
the large vessels, the trachea, and the diaphragm. 

Simple contusions not accompanied by injuries of the 
thoracic viscera are characterized by the presence of ecchymo- 
sis and slight discomfort during the act of respiration. The 
possibility of the presence of a fracture should, however, 
not be lost sight of, even in apparently light cases, the Rontgen 
rays often having furnished the proof of the presence of a 
fracture when simple contusion was assumed. Sometimes 
emphysema of the subcutaneous tissue is observed. 

Treatment. — The main factor in the treatment of simple 
contusion is complete rest, which is attained by the application 
of a moss-board dressing (see page 66) combined with the 
administration of small doses of morphine. The safest plan 
of treatment, for at least the first few days after the injury, is 
to apply the principles of treatment in fracture of the ribs. 
Haematoma of the thoracic wall is treated by compression first 
and by massage later on. 

Wounds of the thoracic wall are treated after common 
aseptic principles. In order to appreciate these fully, attention 
is bestowed best upon those factors which may interfere with their 
thorough execution. They are: the instruments, the dressing 
and suture material on the one hand, and the skin of the 
patient and of the surgeon's hands on the other. In reference 
to the first factors it can safely be maintained that ideal asepsis 
is now an established fact. All objects which stand boiling- 
well can indisputably be made sterile. 



62 Surgery of the Thoracic Wall. 

Easy as the maintenance of asepsis is in regard to all objects 
which stand boiling, so it is difficult in regard to the skin of 
the patient and the hands of the surgeon, Skin bacteria are 
the stumbling-block in the way of perfect asepsis. The 
undeniable fact remains that their total destruction or removal 
is practically impossible. 

The surface of the human body is impregnated with many 
different bacterial species. Some of them adhere to the skin 
surface, some are embedded in the dried cells of the epidermis. 
They are all accessible to sterilization. They do not necessarily 
need destruction, but removal. This can be done by simple 
mechanical means — viz., scrubbing with soap and water. 
It is made so much the easier by preliminary procedures — viz., 
whenever possible, the patient is given a warm bath twenty- 
four hours before operation, the field of operation being 
scrubbed with green soap and shaved while the patient is in 
the bath. Then a poultice of ordinary green soap is applied 
to the skin until shortly before the operation. Thus, thorough 
permeation of the epidermis — the dried cells of which are, in 
fact, macerated by this procedure — is obtained. Before the 
operation the skin is scrubbed energetically with linen com- 
presses which are dipped into semi-fluid soap. This 
soap consists of green soap mixed with soft sand, like sapolio. 
The scrubbing process consumes about two minutes' time, 
and goes on while a stream of very warm water constantly 
flows over the surface to be sterilized. Then thin green soap 
is used in the same manner and for the same length of time. 
Particular attention is given to the folds and creases of the 
skin. Now the skin is dried with an aseptic towel, and rubbed 
for one minute with a gauze compress which is saturated 
with 50 per cent, alcohol. The alcohol is not regarded as 
a disinfectant in the proper sense, but it is mainly used for the 
purpose of removing the fat of the skin, which is a most con- 
genial resting-place for bacteria. By destroying their shelter 
the bacteria are naturally removed. 



Disinfection. 63 

It is self-understood that the means with which asepsis 
should be attained must be aseptic. This refers particularly 
to the water used for washing and the soap, which must have 
been prepared by the boiling process. If brushes are used, 
special care has to be taken, as they can only with difficulty 
be rendered aseptic, thorough cleaning impairing their use- 
fulness . After these vigorous procedures washing with bichlorid 
of mercury or lysol or similar disinfectants is hardly needed. 

There are other similar methods of rendering the surface 
of the skin sterile. If they are thoroughly mastered and carried 
out minutely, they may be employed just as well. But the 
trouble is that underneath the skin surface a number of bacteria 
are sheltered by the glands of the skin, the secretions of which 
offer a favorable soil for their development; and these are not 
accessible to any disinfection or removal. Hence, other means 
have to be chosen to prevent their faculty of infection. And, 
in fact, they will do little harm if cared for properly. 

It is evident that in incising the skin the knife bisects a 
number of glands and thereby exposes the bacteria contained 
by these glands. This undeniable fact fully explains not only 
the so-called suppuration of the stitch-canals, many cases of 
so-called late infection, and the bad reputation of the catgut, 
but also most of the numerous "incomprehensible infections 
which develop under the supervision of the extremely careful 
aseptic surgeon." Here is also the explanation of the suppu- 
ration occurring "in spite of the most minute aseptic pre- 
cautions," which not only astonished many an experimenter 
in his laboratory, but also made him set up new surgical 
doctrines. Bacteriologic tests of aseptic methods, gained 
on artificial soil, cannot be applied to biologic processes, the 
living cell reacting against bacteria differently from gelatin, 
agar, or serum. 

That the bacteria thus set free by the skin incision find 
the most liberal opportunities to come into contact with the 



64 Surgery of the Thoracic Wall. 

deeper regions of the wound need not be emphasized. Still, 
so far as the author's knowledge goes, there are no systematic 
precautions taken or advised in this direction. 

If it is considered that the dissecting knife comes into 
intimate contact with these deep-skin bacteria, generally 
represented by the staphylococcus species, it must necessarily 
be regarded as infected. The hands of the surgeon fall under 
the same considerations. This indicates two necessities — 
in the first place the change of the infected knife, and secondly 
the redisinfection of the surgeon's hands. The latter pro- 
cedure may become unnecessary if gloves are worn by the 
surgeon while the skin is being incised. 

One possibility, however, remains — inoculation of the 
subcutaneous strata with the knife. This danger cannot be 
obviated entirely, but it can be reduced to a minimum by 
slowly and carefully incising the integuments alone as far as 
possible. 

Now, as to the exposed skin bacteria which cannot be 
destroyed or removed : how easy it is to set them hors de combat 
by simple protection! Sterile napkins are fastened to the sub- 
cutaneous tissues with miniature forceps, such as devised by 
the author, so that the skin margins are so well covered by 
them that they do not come into view during all the subsequent 
manipulations, which are done then on an absolutely sterile 
field. 

After the operation is completed the margins should be 
united by the subcutaneous method. If there is a necessity 
for relaxation sutures, they should be applied through the skin, 
but about three-quarters of an inch distant from the wound 
margin, so that there is no direct contact with the wound line. 
For such sutures, however, iodoform silk should be chosen. 
The same principle of protection should, under proper modifica- 
tions, be employed in the opening of deep-seated abscesses. 
(See chapter on Pyo thorax.) 



Disinfection. 65 

The length of time necessary for the scrubbing of the sur- 
geon's hands may vary according to whether the surgeon had 
come in contact with septic cases shortly before sterilization 
or whether he was positive that he had remained clean for at 
least the last twenty-four hours. 

Furthermore, the most particular care must be given to 
the subungual space. Wicked tongues remark of certain 
physicians that they carry graveyards underneath their finger- 
nails. To clean the subungual space a proper nail-cleaner is 
advisable. The nails must be cut short and even with scissors, 
not trimmed with a file. The space is then scrubbed — first 
with the rough soap and then with the alcohol. 

It hardly needs mentioning that the surgeon should wash 
himself frequently, like other decent people, whether he per- 
form an operation just at the time or not. In order to protect 
himself as much as possible he should wear rubber gloves 
when coming in contact with notorious bacterial shelters, 
such as the rectum, or when examining septic cases. He 
should also wash with special care after an operation. 

Whether a wound is a priori infected or not can hardly be 
proved. The state of a wound may with some probability be 
regarded as aseptic if the person who sustained it and the 
wounding object were both clean, and if but little time had 
elapsed before it came under the observation of a surgeon. 
Still, whether aseptic or not, the principles of prophylactic 
disinfection and the carrying out of the disinfecting process 
remain the same as described for patients who are prepared 
for an aseptic operation. 

If there should be a small wound, the surfaces of which will 
agglutinate before infection is possible, union by first intention 
is often secured, provided the premises of secondary infection 
are removed by the prophylactic disinfection. All wounds, 
not inflicted by the aseptic surgeon on aseptic skin, are pri- 
marily painted with tincture of iodine as soon as permissible, 
in order to reach some of the distant bacteria. 

6 



66 Surgery of the Thoracic Wall. 

But if there is extensive injury to the soft tissues, splintering 
of bones, perforation of the thoracic wall, etc., a large incision 
is in order. An attempt should always be made to first locate 
the splinters by the Rontgen rays. The loose splinters must 
be extracted, while those that still maintain an attachment to 
the periosteum should be left. Fragments of fat, muscular 
shreds, fascia or crushed skin and other debris, should also be 
removed. Projecting points of bone should be trimmed off 
with bone-forceps. All haemorrhage must be carefully ar- 
rested; foreign bodies — such as splinters of wood, glass, and 
bullets — are to be extracted. Pockets underneath the integu- 
ment are split wide open. These manipulations should be 
performed only while irrigation with a o.i per cent, sublimate 
solution is maintained. If necessary counter-openings are to 
be made, so as to permit introduction of thorough drainage. 
Great care must be taken that the drains do not come between 
bone fragments. It is inadvisable to apply sutures to 
wounds of this kind. 

After small rubber drains surrounded by iodoform 
gauze are introduced into the counter-openings, the 
wound cavity, especially the pockets, is extensively packed 
with iodoform gauze. The wound is further protected with a 
large amount of some sterile and absorbent material. The 
most desirable substance for this purpose is moss-board, made 
of common German moss, the absorbent power of which is 
five times as great as that of gauze. It represents a very soft 
and adaptable material, and it can be very easily sterilized. 
It is used best by being compressed into a tablet-like shape. 
After being dipped into cold water it adapts itself to the contour 
of the body like a plaster-of-Paris splint, over which it possesses 
the great advantage of being absorbent and much lighter. 
The bulky species of moss-board makes an ideal splint; for, 
should the wound discharge exceed the absorbent power of 
the gauze directly over the wound, it takes up the superfluous 



Wound Dressings. 67 

discharge without impairing the usefulness of the moss as an 
immobilizing factor. To make a moss-splint adaptable it 
must be dipped into, and not soaked in, cold water. If warm 
water is taken, the moss will swell up rapidly and the immo- 
bilization power is lost. If the secretion becomes abundant, 
the center of the moss-board, by absorbing it, swells up naturally, 
but there is so large a portion of the molded moss-splint left 
that its value as an immobilizing apparatus does not become 
impaired any more than does a plaster-of-Paris dressing by 
the cutting of a fenestra. 

If the arteria thoracica longa or mammaria interna or 
intercostalis was injured, the wound must be properly 
enlarged and the vessel tied. This is done after general 
surgical principles. Although wounds of this kind are to 
be regarded as virtually infected, many heal without show- 
ing any reaction, especially if haemostasis is thorough. The 
modus operandi consists in packing the wound with sublimate 
gauze and then cleaning the area with green soap and hot 
water, alcohol, and at last with a 1 : 500 solution of bichloride 
of mercury. Then the antiseptic tampon is removed from the 
wound, the vessels tied, and all crushed or necrotic tissue 
removed. If suturing is resorted to, a gauze drain should be 
left in an angle of the wound. This precaution is so much 
more advisable since it is often uncertain whether there is any 
communication with the pleura or not. 

Non-complicated gunshot wounds require disinfection of 
the integumental area followed by simple protection with 
iodoform gauze (supported by collodion) and immobilization 
by moss-board. In case the arteria mammaria interna is in- 
jured, the pleura is usually penetrated. Haemostasis may be ef- 
fected by tight packing, but the only safe method is tying the 
artery. This is done best by exposing it freely after the 
resection of one or two rib-portions. This method should 
always be tried in doubtful cases in an exploratory sense, since 



68 Surgery of the Thoracic Wall. 

extensive exposure only permits of making a diagnosis of 
the true condition of the pleura. Thus proper steps may 
be taken in time and a fatal outcome averted. If the arterial 
ends cannot be caught in the wound itself, tying may be done 
at a point above the line of incision, beginning at the sternal 
margin and continuing parallel to the rib. 

The intercostal arteries are mostly injured by gunshot or 
stab wounds. Their importance becomes evident by the fact 
that during the Civil War, of fifteen patients who sustained in- 
juries of an intercostal artery eleven succumbed to haemorrhage. 
Fatal haemorrhage from the intercostal artery after thoracic 
puncture as well as open incision is repeatedly reported 
(Billroth). 

Tying of an intercostal artery should never be attempted 
before the rib, which covers it, is resected. By lifting the 
periosteum from the lower surface of the rib the artery 
is drawn aside and is easily seen after the rib-portion is removed. 
(For the details of this operation see page 152.) 

(C) FRACTURE OF STERNUM, RIB, AND COSTAL 
CARTILAGE. 

1. Fracture of the sternum is rare (less than one per cent, 
of all fractures). It is generally produced by direct violence; 
either gunshot wounds or a heavy weight falling upon the 
chest being the causative factors. The line of fracture is 
nearly always transverse. It is but exceptional that it is 
caused by indirect violence (muscular contraction, sudden 
bending of the trunk, the chin being pressed against the 
sternum). 

If caused by a gunshot wound, the seat of the fracture may 
be at any portion of the sternum. Otherwise it is generally 
at the junction of the manubrium with the corpus. 

The signs are local circumscribed pain, more or less dis- 
placement and crepitus, cough, and sometimes haemoptysis 
and dyspnoea. 



Fracture of Sternum and Rib. 



6 9 



The prognosis is favorable except in cases in which there 

is injury done to the mediastinum. 
The treatment consists in re- 
position of the fragments. This 

is accomplished by putting the 

patient into a reclined position by 

placing a large pillow under him, so 

that the receding fragment pro- 
trudes. The head should lie bent 

far backward at the same time. 

If this procedure does not prove 

to be efficient, extension with Glis- 

son's cradle is advisable. 

2. Fracture of the rib, while 

rare in childhood, is frequent in 

adults and represents 15 per cent. 

of all fractures. The injury may 

be caused by direct as well as by 

indirect violence. In the first event 

(blow against the thoracic wall, fall at the margin of the 
sidewalk, staircase, table, etc.) the 
fragments are generally driven in- 
ward (Fig. 51, a). If caused by a 
gunshot, the rib is splintered, the 
intrathoracic organs being gener- 
ally also involved. A simple trans- 
verse fracture may be produced 
by a bullet fired from so great a 
distance that its force is consider- 
ably diminished when it strikes the 
rib. 

If the fracture is caused by in- 
direct violence (as, for instance, 

by compression of the thorax) it is often associated with 




Fracture of the Ster- 
-(Beck's "Fractures.") 




Fig. 50. — Infraction of Ribs 
(no Displacement). — (Beck's 
"Fractures.") 



7° 



Surgery of the Thoracic Wall. 



fracture or contusion of the humerus. In rare instances 
the fracture is produced by muscular contraction, in which 
event the fragments are generally driven outward. 

According to the age of the patient or to the degree of 
violence, an infraction (Fig. 50) or a true fracture (Fig. 51) 
may result. Infractions are much more frequent than frac- 
tures. In children the thorax is so elastic that fracture is 
caused only by a considerable degree of violence. 

The signs consist in intense local pain and in the crepitus 
that results if the fragment is pressed downward by the palm 
of the hand. Manual pressure also increases the painful 





Fig. 51. — A, Fracture op the Inner Costal Table. B, Fracture or the Outer 
Costal Table. 

sensation during the act of inspiration. Deep inspiration and 
stooping toward the opposite side invariably cause great pain. 
If the rib is fractured only, displacement generally does not 
take place; but if several ribs are broken, as shown by Fig. 52, 
considerable displacement may result. 

It is in these cases that the intercostal artery may become 
injured, so that an aneurysm may develop. 

Fractures in the vicinity of the vertebrae impair the func- 
tion of the costotransversal and costovertebral articulations. 

In case the lungs are injured, haemoptysis is always, and 
haemothorax, pneumothorax, and emphysema sometimes, 
present. The last-named condition may extend to the 



Treatment of Fracture of Rib. 71 

neck and abdomen, and in severe cases it may involve the 
whole body, the air escaping from the lung into the surrounding 
connective tissue. The left fourth, fifth, and sixth ribs at 
their sternal junctions endanger the pericardium and vagus, 
while the anterior splinter-fractures of the sixth rib may injure 
the pleural sinus. The right seventh, eighth, and ninth ribs 
may cause laceration of the liver tissue. 

The treatment should be mainly directed to immobilization. 



Fig. 52. — Skiagraph of Fracture of Ribs. 

Taking into account the relation of the ribs to the pleura and 
lung, it is evident that immobilization should not be extended 
upon the thoracic wall alone, but must also affect the intra- 
thoracic organs. 

The first requisite will be attained by the fixation of the 
fragments, which is accomplished by a large and broad strip 
of rubber adhesive plaster or a large piece of moss-board 
applied during expiration. The second and more important 



72 Surgery of the Thoracic Wall. 

requisite, immobilization of the lungs, — in other words, re- 
duction and diminution of the respiratory movements, — is ful- 
filled by a liberal administration of opiates. 

Pleuritis sicca, one of the most frequent results of simple 
infraction as well as of true fracture of a rib, is treated after 
general principles (rest in bed, fomentations, opiates, etc.). 

The same views apply in the much rarer event of pneu- 
monia, which, as a rule, is of moderate extent and significance. 
Sometimes tuberculosis develops after an injury of the pleura 
or the lungs. 

Hemothorax or pneumothorax, if present to a moderate 
extent, demands aspiration, under the most thorough aseptic 
precautions. (Compare page 147.) In most cases, however, 
it is more rational to expose the pleural sac by the resection of 
three or more ribs. The same holds good in pyo thorax. As 
to the technic, compare page 151. 

Pericarditis is not infrequently observed after rib-fracture. 
If a splinter-fragment has pierced the pericardium, injury to 
the heart may also result. The true character of the trauma 
can sometimes be elicited by the Rontgen rays. If, for in- 
stance, the clinical symptoms are slight and the rays show no 
displaced splinters in the direction of the pericardium, medical 
treatment is in order. Even if a bullet, after having fractured 
a rib, has entered the pericardium, there may be no need 
of surgical interference provided no severe symptoms are 
present. An autopsy made by the author on a patient who was 
shot through the thorax eight years before his death, revealed 
a bullet embedded in fibrous tissue in the pericardial sac, 
where it had lodged without ever causing any disturbance. 
(Compare section on Pericardium.) 

But the evidence of a sharp bone-splinter pointing toward 
the pericardium indicates the necessity of exposing the peri- 
cardial sac after the resection of the left fourth, fifth, and sixth 
ribs. They do not necessarily need to be resected in their 



Fracture of 'Costal Cartilages. 73 

totality, but may be folded up at their sternal junctions like 
a bone-flap of the skull. 

It goes without saying that in such cases the clinical symp- 
toms are severe according to the anatomical condition. 

In compound fractures of a rib (Fig. 52) the packing of 
the wound with iodoform gauze is indicated. If there be much 
haemorrhage, the packing must be done tightly and extensively, 
in the form of a tampon bag. 

If the extent of emphysema is moderate, no interference is 
required; but if it be extensive, multiple incisions are indicated. 

To sum up, it can readily be seen that the prognosis of 
fracture of the ribs depends entirely upon the degree of par- 
ticipation of the intrathoracic organs. In simple cases union 
is perfected in from three to four weeks. 

3. Fractures of the costal cartilages occur generally at 
their junction with the ribs, sometimes also in their continuity. 
The consideration of the etiology, signs, and treatment of this 
condition is identical with that of fracture of the ribs. It 
must be considered that in aged people the cartilages become 
ossified. 

Dislocations of the ribs are rare. Reposition is easily done. 
Sometimes severe contusions, not showing any material 
changes of the thoracic walls, are observed {commotion). In 
such cases marked symptoms of shock are prevalent, from 
which the patient is soon resuscitated. 



(D) BURNS OF CHEST. 

Burns of the thoracic wall are especially observed in chil- 
dren who spill boiling liquids on themselves. In adults, burns are 
sustained sometimes by the explosion of gases or projectiles. By 
radial heat burns of the first or second degree are produced 
only. In burns of the 'first degree it is only the epidermis which 
becomes affected, an erythematous condition being the con- 



74 



Surgery of the Thoracic Wall. 



sequence. Acetate of lead with tinctura opii is applied best at 
the early stage, unguentum zinco-salicylicum being indicated 
later, when the acute symptoms have passed and desqua- 
mation begins. 




Fig. 53. — Formation of Dry Eschars after Burn of the Second Degree. 

In burns of the second degree where the heat had a pro- 
longed action the Malpighian layer and the papillae of the skin 
are destroyed besides the epidermis, the result being the 



Burn of the Second Degree. 75 

formation of blisters filled with thin yellowish serum. The 
first step in the treatment is the opening of the blisters and the 
removal of their fragments. Then several layers of 3 per 
cent, iodoform gauze are applied to the denuded surface and 
the whole is protected by a large piece of moss-board which 
is slightly dipped into cold water so that it can be attached to 




Fig. 54. — Circumscribed Burn of the Third Degree, Caused by Red-hot Iron, 
Above the Manubrium Sterni. 

the contours of the thorax. A dressing of this kind immobilizes 
splendidly and absorbs at the same time, so that there is no 
need of changing the dressing before the lapse of a few days. 
When dry eschars have formed (see Fig. 53) unguentum zinco- 
salicylicum may also be used, just as in the first degree. 

In the third degree there is a complete destruction of 



76 Surgery of the Thoracic Wall. 

integument and the subcutaneous, sometimes even of the mus- 
cular tissue, which may be caused by red-hot metal or chemical 
substances. In the beginning a deep dry eschar is formed 
(Fig. 54). The slough generally separates in about a week. 
Where the effect is far-reaching, deep-seated structures being 
affected or a joint being exposed, it is unwise to wait until de- 
composition has taken place. As soon as the shock and con- 
gestive stage (forty-eight hours) are over the patient should be 
anaesthetized and the necrotic tissues removed. Further treat- 
ment consists in loose packing with 3 per cent, iodoform gauze 
and immobilization, preferably by the moss-board mentioned 
above. 

The same principles of treatment should be obeyed if 
there are all degrees found mixed on a burned surface. If 
the surface is very large, iodoform gauze should be used for the 
deep sloughs only. It should be considered that in severe 
burns of the thoracic wall the pleurae and lungs become con- 
gested (in rare cases serothorax and pyo thorax even being caused). 
This will favor asphyxia from carbonic acid absorption . It should 
be appreciated that if intoxication from the partly broken up 
portions of the burned area takes place besides, the chances of 
the patient become very poor. We should therefore eliminate 
at least one of these dangerous factors — i.e., absorption — which 
we are able to do by following strenuous aseptic principles. 
The fact should never be lost sight of, that burns are nothing else 
but wounds and must therefore be treated as such, and that 
many of those internal alterations like duodenal ulcers, which 
puzzle us so much, are undoubtedly caused by the indirect 
influence of septic irritants. 

The internal treatment consists mainly in the administra- 
tion of stimulants during the first days, when there were signs 
of collapse. To promote oxygenation of the blood frequent 
inhalations of oxygen are in order. Strophanthus, caffeine, or 
strychnine may be given besides. 



Various Degrees of Burns. 



77 




FlG - 55- — Extensive Burn (caused by Flame) Showing All Three Degrees. 
First degree, at the periphery; second degree, from the right sternal margin to 
the left mammilla; third degree, over the right mammilla and at the anterior surface 
of the arms. 



7 8 



Surgery of the Thoracic Wall. 



In extreme cases of the third degree skin-grafting is fre- 
quently indicated (Fig. 56). Sometimes, a portion of a large 
defect heals under the stimulating influence of the continuous 




Fig. 56. — Burn of Third Degree, Reaching from Both Mammillae down to 
the Umbilicus, the Upper Hale being Cicatrized after Three Months, 
While the Lower Portion is still Ulcerating. (Closure by Skin Grafting. 



application of a bichloride of mercury solution (1: 5000), while 
other portions resist all these efforts. 




Fig. 57. — Contraction by Burns from the Axilla Downwards. 




Fig. 58. — Axillary Flap Transplanted prom Dorsum. (Compare Fig. 57.) 
79 



8o 



Surgery of the Thoracic Wall. 



In other cases cicatrization of even extensive surfaces takes 
place sometimes, but at the expense of functional ability (Fig. 57.) 
Then simple skin-grafting will not suffice. Large flaps must 
then be borrowed from the vicinity, as in the case illustrated 
by Fig. 58, where a flap was obtained from the dorsum. This 




Fig. 59. — Burn of the Third Degree, Extending over the Whole Anterior 
Surface of the Chest and the Right Side of Neck and of Lower Portions 
of Face. (Treated by Repeated Skin-grafting.) 



was turned forward and implanted into the axillary region, a 
procedure which permitted of lifting the arm. 

When the whole anterior surface of the thorax is deeply 
burned, plastic resection should be made before cicatrization is 
complete. In such cases, as they are illustrated by Figs. 57 and 





Fig. 60. — Extensive Scar of Side of Dorsum, Caused by the Explosion of an 
Ammunition Box in the Battle of Gettysburg (Note Epithelioma in the 
Scar Forty-two Years Later). 




Fig. 



61. — Rontgen Burn, Second Degree (after Removal of Blister). 
7 Si 



82 Surgery of the Thoracic Wall. 

59, transplantation is especially to be made from the abdomen, 
thick integumental flaps, which are to be resected, giving the 
best guarantee for the reformation of good skin tissue. 

Old scars are a source of greater or lesser disturbance even 
if they do not disturb important functional abilities. In aged 
people a scar may favor the development of carcinoma, as in 
the case of the venerable hero, illustrated by Fig. 60. 

Burns caused by the excessive use of the Rontgen rays fall 
under the same considerations (see Fig. 61). 



(E) CONTUSION OF THE THORAX ASSOCIATED WITH 
INJURIES OF THE INTRATHORACIC ORGANS. 

Contusions of this severe kind are generally associated 
with fracture of the ribs. (See page 69.) The clinical symp- 
toms vary according to the degree and site of the destruc- 
tion. If the lungs are lacerated the signs are grave, marked 
shock (cyanosis, anaemia, cold extremities, tremor), dyspnoea, 
and haemoptysis generally being present. 

Haemorrhage in the pleural sac causes haemothorax, so that 
the symptoms of pressure prevail. In most cases a large 
area of dullness develops quickly, the breathing sounds as 
well as vocal fremitus disappearing gradually in proportion. 
(Compare section on haemothorax, page 201.) Tearing 
of the lung tissue produces pneumothorax, the physical 
signs of . which vanish in the presence of the high- 
pitched tympanitic note on percussion and amphoric breath- 
ing on auscultation. In favorable cases the effused air is 
slowly absorbed, expansion of the lungs taking place. 

While the prognosis of these non-penetrating intrathoracic 
injuries is serious, still it is not as grave as that of the pene- 
trating type. 

Treatment. — The therapy instituted immediately after 



Penetrating Injuries of the Thorax. 83 

the injury is placing the patient in the horizontal posi- 
tion and administering stimulants (injection of camphorated 
oil, and subcutaneous saline infusions). An ice-bag may be 
applied to the thorax. If the heart is displaced by the formation 
of a large bloody effusion, aspiration under the most thorough 
aseptic precautions is indicated (see pp. 132 and 147, on aspir- 
ation) . Subsequent effects of intrathoracic contusion, especially 
pleuropneumonia, are treated after the usual methods. Sero- 
thorax and haemothorax require aspiration, while purulent 
effusions demand thorough exposure after rib-resection. 



(F) PENETRATING INJURIES OF THE THORAX. 

Injuries to the intrathoracic organs are followed by effects 
similar to those of the non-penetrating type, the main difference 
consisting in the possibility of carrying infection into the pleu- 
ral sac or the lungs. The blood arising from the laceration of 
lung tissue or from the arteria mammaria interna or intercos- 
talis can escape freely through the external opening, thus pre- 
venting the formation of haemothorax. It must be remembered 
that, in the normal state, the lungs fill the two lateral 
halves of the thorax completely, an intimate contact existing 
between the pulmonal and costal pleurae. The pleurae can 
be compared with two moist glass plates which can be moved 
under normal conditions but not be lifted off. It is only by 
the formation of an effusion between these membranes as the 
result of a pathological process (hydro-, sero-, or pyo-thorax), 
or by the presence of blood or air as a result of a trauma 
(haemothorax and pneumothorax), that this air-tight seclu- 
sion is disturbed. 

Signs. — While the signs may be so insignificant in those 
cases in which neither blood nor air escapes in the pleural sac 
that the injury of the pleura may be overlooked, they are 
of great severity when the pleura is widely opened. Then, 



84 Surgery of the Thoracic Wall. 

of course, pneumothorax develops rapidly. Physical examina- 
tion shows a large tympanitic area. There is considerable 
dyspnoea, the pulse becomes small and irregular, and the 
patient may succumb to the reflectory paralysis of heart and 
lungs. Often, however, the patient survives the shock, and 
the question of his final recovery hinges upon the degree and 
character of the simultaneous infection. If there was no 
infection the air will be slowly absorbed. But in case of 
infection an effusion forms under septic symptoms, the pulse 
being small and rapid, while the temperature is high at the 
beginning and becomes low or even subnormal in the further 
course. The heart, the lungs, and the diaphragm being 
compressed and displaced by the effusion, it is natural that 
the dyspnoea assumes a grave character. If the patient tries 
to assume the recumbent position, he will become cyanotic. 
The physical signs show dullness on percussion, while aus- 
cultation is unable to detect any breathing sounds. The tho- 
racic wall protrudes and the intercostal spaces are filled up. 

Stab wounds are more prone to infection than gunshot 
wounds. Whether the pleura alone is injured, or whether 
the lungs participate, cannot always be elicited. If haemop- 
tysis, the most characteristic sign of pulmonal injury, is ab- 
sent, and if the pneumothorax disappears rapidly an isolated 
injury appears to be present. The prognosis is favorable in 
such a case. 

It is obvious that in most instances those means which in- 
jure the costal pleura are apt to perforate the lungs at the same 
time. Large bullets generally penetrate the lungs in their en- 
tirety, making their exit at the opposite thoracic wall, while 
revolving bullets often are arrested by a rib or a vertebra. If 
rib, sternum, or vertebra is penetrated, bone splinters may be 
carried into the pulmonal parenchyma. (For diagnosis see 
page 68, on Fractures.) 

As alluded to above, the symptoms of a pulmonal injury 



Signs of Pulmonal Injury. 85 

are not always in proportion to their extent. In cases which 
terminated fatally after days or weeks, the autopsies showed 
the most extensive destructions, and still the patients were 
able to walk a distance or to continue fighting in battle shortly 
after having sustained their injuries. On the other hand, 
there may be marked shock, the patient becoming uncon- 
scious immediately after being wounded, and still recovery 
takes place rapidly. In a number of patients anaemia and 
cyanosis, tremor, cold perspiration, and facies hippocratica 
are observed. There is intense pain, which is sometimes 
located on the abdomen, and violent cough. The heart beats 
faintly, the pulse is irregular and hardly perceptible, the 
respiration shallow, superficial, and frequent. If the patients 
pass over the shock, the symptoms of haemothorax, sometimes 
of haemo-pneumothorax, are in the foreground (see above). 
Haemorrhage from the small blood-vessels stops spontaneously, 
an occurrence which is favored by the collapse and compres- 
sion of the tissues involved. 

Prolapse of lung tissue as well as emphysema are more 
frequently found in stab than in gunshot wounds, emphysema 
confining itself, as a rule, to the immediate vicinity of the 
wound. Prolapse is rare, however. In the Civil War only 
seven cases were observed. 

In gunshot wounds produced by the modern small-calibre 
bullet the smooth canal favors coaptation, which in regard to 
the openings in the costal and pulmonal pleura is of special im- 
portance. Projectiles are generally aseptic, but the fragments 
of cloth, etc., which they often carry with them represent a dan- 
gerous source of infection. If primary union did not take place, 
the canal having been infected by the knife or projectile or other 
wounding instrument, the bloody effusion decomposes rapidly, 
foci forming in the lung tissue at the same time. Phlegmonous 
or gangrenous processes may be the consequence. Later on, 
the pericardium as well as the mediastinum may participate. 



86 Surgery of the Thoracic Wall. 

Statistics show that among twelve injuries there is one of 
the chest, and that the penetrating type figures with 40 per cent., 
the mortality rate amounting to about 60 per cent. 

Treatment. — The therapy of penetrating wounds of the 
chest consists in the treatment of the wound itself (disinfection 
and control of haemorrhage) as well as of the primary symptoms 
described above (page 66). The principles of wound treatment 
as elicited above must be applied in the first place. If a pro- 
jectile has caused the injury, the Rontgen method must 
finally settle the question whether an attempt at extraction 
should be made. As a rule, the treatment of the wound-canal 
and of the symptoms is of much greater importance than the 
removal of the bullet. The treatment par excellence in the 
majority of cases is the aseptic packing, preferably done 
by iodoform gauze. The internal treatment is virtually the 
same as is the non-penetrating kind, particular stress being 
laid on exterior and interior immobilization (morphine injec- 
tions). Only if dyspnoea becomes severe, aspiration of the 
haemorrhagic effusion (in the fifth or sixth intercostal space) 
must be undertaken. Isolated ligation of the pulmonal 
wounds must be regarded as a technical impossibility, but 
ligature en masse may sometimes be tried advantageously. 
In most cases the aseptic tampon must be resorted to. 
Pneumothorax and emphysema are not amenable to any special 
therapy. Secondary symptoms, like purulent effusion, are 
combated by thoracotomy preceded by rib-resection in about 
the middle of the axillary line. (As to details of the opera- 
tion, see page 152.) 



(G) INFLAMMATORY PROCESSES OF THE CHEST- WALL. 

Furuncles and carbuncles show a marked predilection 
for the back, whose integumental sphere, so rich in sebaceous 
follicles, favors the formation of comedos and of acne. In 



Carbuncle. 87 

America, where the skin receives more careful attention than 
anywhere else, most people taking a daily bath, this tendency is 
not pronounced. Most cases of carbuncles are observed among 
the foreign elements and very little among Americans to the 
manor born. Formation of an acne pustule, as it may be pro- 
duced by the friction of the clothing around the scapulae or the 
lower part of the neck, increases the area of infection, the result 
being a more or less extensive folliculitis called furuncle. 

The carbuncle is the same process virtually, the difference 
being one of degree and not of kind, the subcutaneous connective 
tissue becomes infiltrated and the integument finally perforated 
at various places. There is a small amount of liquid pus, as a 
rule, surrounding necrotic portions of tissue. 

The usual diameter of a carbuncle amounts to several inches, 
while the infiltration generally reaches far down in the depths. 
There is a slight elevation, generally of a circular form, the 
coloration being dark red or coppery. 

In all cases of furunculosis or carbunculosis the possibility 
of the presence of Bright's disease, diabetes, and other de- 
bilitating affections must be thought of. 

Treatment. — Small furuncles, if observed at their early 
stage, may be absorbed by the injection of two to three drops 
of pure carbolic acid into the center. 

In the advanced stages of furunculosis and in all cases of 
carbuncle the most radical steps must be taken. 

Since the early day of antisepsis, the author learned to treat 
carbuncle by crucial incision, removal of the softened necrotic 
parts with forceps, scissors, and curette, and by the application 
of strong antiseptic fluids. But such procedures were seldom 
followed by that immediate relief which is so characteristic a 
sign after the evacuation of a pus-cavity. 

The following day always revealed new foci, demanding 
repetition of the painful procedures. And the same manoeuvre 
had to be repeated day after day for at least a week, sometimes 



88 Surgery of the Thoracic Wall. 

much longer, until the black and grayish sloughs were replaced 
by a deep, irregular, crater-like ulcer, covered by granulations. 
Clinical experience having shown that whenever carbuncle was 
diagnosticated such a course was certain, in a more or less 
pronounced degree, and that we never succeeded in " aborting " 
a carbuncle ; also, considering the bacteriological significance of 
carbuncle, the question was obvious: "Why leave the unavoid- 
able process of destruction to Nature while it is within our easy 
reach to destroy the focus at its early stage by excising it in its 
totality?" 1 

From a clinical point of view, carbuncle is nothing but a 
collection of small furuncles, lying closely together, so that the 
integument appears perforated like a sieve, by separate in- 
flamed and necrotic foci. Bacteriologically, we know such foci 
are caused by infection of pus-producing bacteria. It is in- 
conceivable, therefore, that by simply dividing a few joci by 
crucial incision thorough disinfection should be obtained. As 
soon as infection has spread to the subcutaneous cellular tissue, it 
extends peripherally. It is true that at its seat of predilection, 
the upper dorsum, the carbuncle infection is generally arrested 
at the dense fascia protecting the muscular tissue, while in the 
face the anatomical relations favor spreading, thrombosis of the 
facial vein, suppurative phlebitis, participation of the middle 
meningeal and jugular veins. Thus the fatal course is fre- 
quently explained on the autopsy- table. 

Ordinarily, infiltration so increases the density of the integu- 
ment that it does not yield to the great amount of pressure ex- 
erted by the pus forming below; it, therefore, cannot find its 
outlet before some of its portions undergo gangrene. Conse- 
quently, bacteria and pus must wander from one interspace to 
another, thus gradually involving the deep structures. 

The bacteria which merit preeminent consideration in con- 

1 See "The Radical Treatment of Carbuncle." The Clinical Recorder, January, 



Extirpation of Carbuncle. 89 

nection with carbuncle are the staphylococcus aureus and albus. 
Schimmelbusch and Garre rubbed pure cultures of these cocci 
into the skin of their arms and produced carbuncle, in the puru- 
lent discharge of which they found staphylococci again.. The 
cocci invaded the tissues alongside the hairs, between shaft and 
root. Still, in many cases, the streptococcus, as well as the dif- 
ferent varieties of proteus, and the anthrax bacillus were found. 
As is well known, the latter is regarded as the most virulent of 
all bacteria. It is evident that inoculation with different bacteria 
means different diseases, no matter how much alike the clinical 
symptoms may be. In the beginning all carbuncles look very 
much alike, and it is only in the further course of the disease that 
clinically a greater or lesser toxic influence becomes marked. 
Consequently, the greater and lesser virulence of the infecting 
bacteria, besides the more or less favorably situated locality, may 
be held responsible for the termination of the case. It would be 
fair to assume that a staphylomycosis, other circumstances be- 
ing equal, may not lead to a fatal end as easily as the invasion of 
the highly virulent bacillus anthracis might. From these con- 
siderations, it may appear opportune to make bacteriological in- 
vestigations of each case of carbuncle at its very beginning, and 
to deduce from the toxic gravity of the case. Unfortunately, 
such examinations consume too great a length of time to be 
utilized under ordinary circumstances where prompt action is 
urgent. Furthermore, the busy practitioner is not always 
equipped with all the means necessary for such investigations. 
In view of these facts it seems practicable to look upon the 
virulent significance of each case of carbuncle as grave, and to 
act accordingly. 

As the infiltrated tissue must be eliminated at all hazards, be 
it infected by whatever bacteria, it is better to sacrifice it at once, 
and to remove it with its disastrous inhabitants. This common 
surgical principle is widely adhered to in other surgical diseases, 
and there is no reason whv it should be abandoned in connection 



90 Surgery of the Thoracic Wall. 

with carbuncle. The results which the author obtained since 
he made it a rule not to incise, but to excise at once, no matter 
what bacteria caused the infection, or whether there was any 
constitutional disease, like diabetes, or not, have been extremely 
gratifying. 

The technic of the operation, as it should be performed, 
either under a local or a general anaesthetic, is as follows: 

After thorough aseptic precautions, the center of the in- 
filtrated mass is caught by a strong Muzeux forceps. An incision 
is then made around the margin of the reddened area and carried 
down to the deeper tissues (fascia, if in the upper dorsal region). 
While lifting the infiltrated mass by the forceps, it is rapidly 
severed from the underlying tissues. The haemorrhage follow- 
ing the operation is not at all excessive, and can be kept in check 
by packing tightly with iodoform gauze. A gauze dressing 
saturated with a strong solution of bichlorid of mercury is then 
employed until the wound granulates well. The immediate 
effect of this method is simply surprising. The general dis- 
turbance, the pain, fever, and the delirious state of the patient 
disappear at once. Even if performed without an anaesthetic, 
this operation is less cruel than the method of crucial incision. 
A circular incision does not cause more pain than the crucial, 
and after the incision the patient does not require any further 
operative interference, while after incision he is obliged for 
weeks to daily suffer the torture of scissors and curette. 



(H) PHLEGMON OF THE THORACIC WALL; GENUINE 
AND TUBERCULOUS ABSCESSES; NECROSIS. 

True phlegmon of the thoracic wall is rare. It generally 
originates from suppurating glands of the axilla, wherefrom it 
propagates alongside the anterior chest-wall and on the fascia 
which is protected by the pectoralis major muscle. Finally the 
muscular tissues are invaded and an elevation at the sub- 



Phlegmon of Thoracic Wall. 91 

clavicular fossa points to the nature of the process. In ex- 
ceptional cases the etiological factor is a deep-seated foreign 
body, like a needle-fragment, which causes an abscess. 

The symptoms of phlegmon of the thorax are grave. Early 
and extensive incision followed by liberal packing with 3 per 
cent, iodoform gauze give the only chance for recovery. Cases 



Fig. 62. — Osteomyelitic Rib-abscess. 

which were recognized at a later period generally take a fatal 
course in spite of the radical interference. 

Abscess formation caused by a foreign body gives a much 
more favorable prognosis. The same applies to hematoma 
produced by an injury, after it started to suppurate, provided 
a wide opening is made without delay. 

In extraordinary cases an abscess may be the result of 



9 2 



Surgery of the Thoracic Wall. 



osteomyelitis of the sternum or one of the ribs. They are es- 
pecially observed among the sequelae of typhoid fever. Their 
treatment consists largely in the resection of the affected bone 
portiom(Fig. 66). 

So-called cold abscesses of the thoracic wall mav sometimes 




Fig. 63. — So-called Cold Abscess Caused by Caries of the Second Rib. 

be caused by caries (Figs. 62, 63, and 64), but as a rule they 
are due to tuberculous osteo-periostitis. When the abscess is 
accessible, it is best treated by aspiration followed by the 
injection of a 10 per cent, emulsion of iodoform-glycerin. 

For diagnostic purposes the injection of iodoform-glycerin 
can also be utilized, since this substance is permeable by the 



Injection of Iodoform-glycerin. 93 

Rontgen rays. It can therefore be recognized on a photogra- 
phic plate after being injected into the abscess-cavity. The 
extent of the cavity, as well as of any deep-seated fistula, can 
thus be elicited. 

Regarding the peculiar influence of iodoform upon tubercu- 
lous tissue the findings of the laboratory harmonize entirely with 
clinical experience. Bruns and Nauwerck, who excised the 
membranes of tuberculous abscesses, which had been treated 
with iodoform-glycerin, found neither tubercle bacilli nor 
tuberculous nodules nor any caseous or necrotic areas. The 
author could corroborate this statement by his findings in those 
cases which submitted to operative corrections of deformities, 
after the tuberculous process was cured by the iodoform treat- 
ment. The formerly tuberculous areas were replaced by firm, 
normal, vascular tissue. At first the tuberculous structures 
underwent fatty degeneration and partial necrosis ; later cicatri- 
zation took place . 

The addition of glycerin enhances the effect of the procedure, 
as the alteration of the tissues caused by it (especially the 
hyperemia, which in itself is a curative factor, followed by cell 
infiltration) favors the tissue changes, the slight inflammatory 
reaction intensifying the influence of the iodoform. The in- 
nocuous and non-irritating olive oil should, therefore, not be 
used as a vehicle of iodoform in cases of tuberculosis. That 
glycerin is an alterative becomes evident from the fact that after 
the intra-articular injection of pure glycerin a slight elevation of 
temperature and an acceleration of the pulse is observed. Ex- 
amination of the urine always reveals the presence of red blood- 
corpuscles; in severer forms of acute glycerin intoxication 
hyaline casts are even found. 

The addition of other drugs or vehicles (mucilage) keeps 
the iodoform well suspended in the emulsion, but their ad- 
mixture always impairs the influence of the iodoform more or 
less. The author has, therefore, used the simple emulsion, con- 



94 Surgery of the Thoracic Wall. 

taining iodoform 10, and glycerin ioo parts. The iodoform settles 
at the bottom of the glass vessel, therefore the emulsion must be 
well shaken before use. The emulsion must be sterilized. This 
is done by filling a glass bottle with it and exposing it to the 
steam of a sterilizer for about an hour. The bottle should not 
be closed by a stopper, lest pure iodine be set free. The 
amount injected is ten cubic centimetres of the emulsion in 
children and twenty to thirty in adults on an average. 

It must always be considered that an injection has the 
dignity of a surgical operation, and that it, therefore, should be 
viewed from a strictly surgical standpoint. Especially should 
it be preceded by the same preliminary precautions, viz., 
sterilization of the puncturing apparatus, of the hands of the 
surgeon, and of the region to be punctured. 

Ordinary hypodermic syringes must not be used, because 
they do not stand boiling without being injured, nor do they 
.draw thick fluids. Another objection to them is that thin 
needles break easily if they have to be pushed down into re- 
sistant tissues. The author uses a strong syringe, the piston of 
which is so arranged that it can be propelled by a screw (Fig. 80). 
This arrangement prevents the surgeon from using too much 
force. At the same time it is provided with two stop-cocks, 
which permit aspiration of fluid as well as injection, while the 
needle remains in the joint. The needle itself must be especially 
strong and of large calibre. In early cases one injection is some- 
times sufficient. If there is intense reaction, which, if the above 
precautions are observed, is of rather rare occurrence, the in- 
jections must be deferred until the signs of reaction are over. 

As a rule, the injection is repeated every week until there is 
considerable improvement. 

Should there be no improvement after the injections have 
been repeated twice, wide exposure of the joint according to 
exploratory principles is indicated. This will seldom be neces- 
sary if suitable cases come under early observation. 



Mode of Iodoform Treatment. 95 

The needle must be introduced slowly. Local anaesthesia is 
seldom needed. In nervous patients ethyl chloride may be 
used. All aspirations and injections should be done in the 
recumbent position. If this modus operandi is adhered to 
little reaction is to be expected. There is generally a slight rise 
of temperature. If the patient is kept quiet the pain, which 
follows occasionally, is insignificant. 

The reports of iodoform poisoning, so often heard in former 
years, have become scarce. The author has never been able 
to observe an undisputed case of general iodoform poisoning, 
although he used the iodoform since 1878, when he first made its 
acquaintance at Simon's clinic in Berlin. Then it was applied 
in a limited way only, but ever since the publication of 
von Mosetig-Moorhof he has used it moderately, as there is no 
need for excessive administration. It is true that the iodoform 
reaction is often found in the urine, as well as in the saliva, a few 
hours after the injection, but there were no other signs besides, 
and it is hardly justifiable to call this a poisoning. 

Abscesses of the thoracic wall may also be produced by 
peripleuritic abscesses or by a so-called empyema necessitatis 
(Fig. 92), that is, by the perforation of an empyema pleura. 
Both processes may show the same clinical signs. 

Perforating abscess of the lung may also discharge itself be- 
low the thoracic skin by a slow process, the pleurae becoming 
fibrous and finally adherent to each other. 

These conditions are specially considered under their in- 
dividual headings further below. As to differentiation it must 
be borne in mind that they may be confounded with aneurysms 
of the aorta (see Figs. 114- 120), pulmonal hernia, and caver- 
nous angioma. 

At its initial stage tuberculosis may attack one rib only, 
tracking alongside of it and thinning it so that it may in fact 
fracture it finally. Other ribs may participate, if early inter- 
ference is omitted. In neglected cases sternum, clavicle, and 



9 6 



Surgery of the Thoracic Wall. 



even the vertebrae may be invaded at the same time, so that 
an attenuation of the whole half of the chest-wall will be the 




Fig. 64. — So-called Cold Abscess Due to Tuberculosis of Sternum at the 
Ensdjorm Process. 



consequence, many "cold" abscesses of smaller and larger 
size indicating the nature of the disease. 



Tuberculous Abscess. 97 

No matter how slight the first symptoms are, the surgeon 
should regard any painless swelling, which is forming slowly, 
with great suspicion, and consider the possibility of abscess 
originating from a tuberculous focus in rib or sternum. In 
this stage aspiration, followed by repeated injection of a 
10 per cent, iodoform-glycerin emulsion, nearly invariably 
effects a cure. Of course, constitutional treatment, viz., out- 
door exercise, cod-liver oil, sea-salt bathing, guaiacol, and sun- 
baths, must be administered at the same time. 

If the abscess formation extends far inward, pyothorax 
may be diagnosticated. When the history does not indicate 
the nature of the case, the Rontgen method will 
differentiate, because in pyothorax the outlines of ribs or 
sternum would appear intact, while in tuberculous caries 
they would show the signs of arrosion and destruction. The 
calcareous matter would also be more completely absorbed in 
caries than in pyothorax; in the latter event there are no 
visible changes in the bone-shadow at an early stage. 

There is little tendency to perforation. In old cases the 
abscess makes an attempt to sink far into the lungs. The pleurae 
protect themselves against perforation by becoming much 
thickened, thus forming a resistant wall against invasion. 
Sometimes the abscess may appear in the loin, the exterior 
part of the abdomen, or it may wander alongside the sheath 
of the psoas muscle and emerge from below Poupart's liga- 
ment (psoas or iliac abscess) (Fig. 65). 

If the circumscribed character of the abscess has become 
lost and the rib or sternum become completely destroyed by 
degrees, the affected bone portions must be removed together 
with the tuberculous tissue enveloping them. Most of the 
degenerated tissue can be scraped away. Sometimes there 
are very thick fibrous masses, which can be extirpated only 
by use of the scalpel. Thorough removal is just as necessary 
as if a carcinomatous tumor was to be extirpated. Part of the 



9 8 



Surgery of the Thoracic Wall. 



wound may be sewed up, while the remainder should be packed 
with iodoform gauze. 

If tuberculosis starts in the sternum it must be realized that 
the peculiar form and texture of this bone, protected by its 
tough posterior membrane, gives the disease a chance to 
spread widely before the abscess breaks through an inter- 
costal space. This explains why at the initial stage a correct 




Fig. 65. — Emaciation after Tuberculous Rib-abscess, in a Boy of Twelve 

Years. 

Note protrusion under left rib-arch. 

diagnosis is seldom made, especially when, as it is the rule, 
the process originates from the posterior surface. 

Sometimes perforation into the loose areolar tissue of the 
mediastinum takes place where access is extremely difficult. 
But in the majority of cases the strong fibrous membrane 
which invests the posterior sternal surface is strong enough to 
prevent this fatal occurrence. 

The technic of the operation in such cases consists in the 



Resection of Sternum and Ribs. 



99 



extensive exposure of the foci. The author usually makes a 
longitudinal incision at the outer margin of the sternum near 
the swollen area, following the exploratory principle em- 
phasized in the section on costal resection. If the ribs appear 
to be diseased a transverse incision is added as illustrated by 




Fig. 66. — Tuberculosis of Sternum and Ribs (Cured by Extensive Resection). 



Fig. 66, which shows the result of removal of the left margin 
of the sternum and of portions of the third, fourth, fifth, and 
sixth ribs, in a man of fifty-eight years. 

Sometimes the sternum becomes so much softened by the 
disease that most of it can be removed by the sharp spoon. 

tOFC. 



ioo Surgery of the Thoracic Wall. 

Hard portions, covering the focus, must be resected by chisel or 
rongeur forceps. It is astonishing how quickly patients who 
are often given up as cases of incurable phthisis rally after 
thorough removal of the diseased area is done. The hectic 
fever caused by absorption disappears promptly when pus- 
formation stops, and the patients improve rapidly, provided 
no further foci have been established in the depths. 

Tuberculous osteomyelitis of the ribs starts by first forming 
a small central focus, which gradually extends toward the 
periphery. The nearest sphere of the periosteum proliferates 
more and more in that it becomes very much thickened. 
In the further progress of these changes the other tissues, espe- 
cially the fascia, participate. Finally an abscess forms, which 
perforates through the integument, thus establishing a fistulous 
tract. In some cases various foci form at different parts 
of the same rib. Tuberculous periostitis of the rib is extremely 
rare. Its course is slow, the rib usually becoming necrotic 
and exfoliating itself from the periosteal coat. 

Tuberculous osteomyelitis falls under the same considera- 
tions. 

The prognosis of tuberculous osteomyelitis is favorable if 
the iodoform- treatment is begun early. When fistulae have 
formed the iodoform- treatment is generally unsuccessful. Ex- 
tensive resection and removal of the thickened membranes 
followed by packing with iodoform gauze is indicated then 
(see section on rib-resection). 

Syphilitic inflammation of sternum or rib shows a great 
similarity to tuberculous processes. It seems that in the 
majority of cases syphilitic pus is more viscid and homogeneous 
than the tuberculous, the latter also showing a cheesy character. 
But these signs are not absolutely reliable. It must also be 
considered that syphilis and tuberculosis may be present in 
the same individual. 

Anatomically it may be emphasized that the syphilitic 



Actinomycosis of Chest-wall. 101 

inflammation originates from the periosteum. A good skia- 
graph may be able to demonstrate that fact, thus settling the 
question of differentiation. The best method of differentiation, 
however, seems to the author to be to administer antisyphilitic 
treatment. If there is marked improvement, the diagnosis of 
syphilis is justified. Inunctions as well as the internal use of 
iodide of potassium (one to two drachms pro die) are recom- 
mended. 

The prognosis is unfavorable, the patients generally suc- 
cumbing to the emaciation. A most radical therapy, however 
(excision of fistulae and energetic cauterization with Paquelin's 
cautery), was followed by recovery in a few instances. 

Actinomycosis of the chest-wall is not infrequently ob- 
served, dental caries often presenting a predisposing moment 
for the invasion of the actinomyces into the mouth, pharynx, 
and the lungs. There an abscess forms rapidly then, from 
which numerous fistulae establish themselves. The diagnosis 
can be verified by the microscope only; although the multi- 
plicity of the abscess is a pathognomonic factor. 



I. TUMORS OF THE CHEST- WALL. 

Tumors of the chest-wall are divided best into benign and 
malignant. They originate from the osseous structures as 
well as from the soft tissues. 

i. Benign Growths. — Sebaceous cysts and dermoids are 
found at the dorsum with moderate frequency. They are 
sometimes confounded with abscesses and other types of cyst- 
formation. Their removal under local anaesthesia is easy. 

Lipoma shows great predilection for the dorsum, where 
it is observed with considerable frequency. It is always 
lobulated, which makes its recognition easy. 

Retromammary lipoma, a rare and peculiar type, is charac- 
terized by its development at the expense of the mammary 



102 Surgery of the Thoracic Wall. 

gland, which becomes atrophied in proportion to the growth 
of the lipoma. Lipoma does not annoy the patient except 
when it becomes very large. 

The only therapy consists in extirpation, which does not 
offer any technical difficulties under ordinary circumstances. 

Fibroma is nearly as frequent as lipoma. In contradis- 
tinction to the doughy consistency of lipoma it shows a firm 
and resistant structure and is not as freely movable. Its 
seat is submuscular, its growth slow, and its usual size that of 
a walnut. As a rule, extirpation of ordinary fibroma is easy, 
but when there are any intimate connections with the pleura, 
as it happens sometimes, thorough removal reaches the dignity 
of a serious operation. 

Fibroma molluscum (cutis pendula) is found directly under 
the skin and originates from the perineurium. Its consistency 
is extremely soft. This variety extends over the whole body, 
sometimes as a multiple type, hundreds of nodules of larger 
and smaller sizes being observed then. The presence of a 
few nodules does not cause any disturbance, while the multiple 
variety gives rise to considerable trouble. The removal of 
the numerous tumors should then be undertaken in several 
seances. 

Keloid of the thoracic integument is a fibrous nodular mass 
of a gray, sometimes of a pinkish color, and is generally 
multiple. As a rule, the etiology is unknown, but it may well 
be assumed that a trauma, which remained unnoticed, gives 
the first impetus in individuals who have a peculiar idiosyn- 
crasy. As mentioned above, the integument of the dorsum 
is characterized by the presence of numerous follicles, which ex- 
plains its predisposition for the development of acne. From pro- 
liferations around the acne-pustules a real keloid-acne may 
arise. Sometimes they reach considerable size, in which 
case they generally produce neuralgic disturbances. Extir- 
pation should be performed under the most pressing circum- 



Naevus of Chest-wall. 



103 



stances only, because the tendency to recurrence is enormous. 
The removal of the growth should, therefore, always be followed 
by the transplantation of an unquestionably healthy skin-flap. 
Some cases showed improvement under careful Rontgen treat- 
ment following extirpation (Fig. 67). 

Naevus is especially frequent in children. It is generally 




* 




Fig. 67. — Multiple Keloid of Chest, Dorsum, Neck, and Face. 



of small size, but exceptionally it may reach the extent of 
the circumference of an orange. Its dark pigmented ap- 
pearance makes its recognition easy. The therapy consists 
in the speedy removal by the scalpel. In order to reduce 
haemorrhage the author's prophylactic suture-method is recom- 
mended. 

Cavernous haemangioma is not infrequently found on the 



104 Surgery of the Thoracic Wall. 

thoracic wall. It shows two different types, one of them 
being characterized by flat formations of a light or dark red 
color and of various sizes, the other showing a cystic structure 
with lobulated margins (Fig. 68). 

As far as treatment is concerned, it may be said that while 
small haemangiomata may be removed by galvanocautery, 
or by the Paquelin instrument, extirpation by the scalpel is to be 



Fig. 68. — Cavernous Hemangioma Extending from the Anterior Axillary 
Line to the Spine in a Boy oe Six Months. (Recovery after Extirpation.) 



preferred whenever possible. The prophylactic suture is highly 
recommended, especially in infants, where even a small amount 
of haemorrhage may be disastrous. 

Neuroma is closely related to fibroma, because fibroma, 
in fact, originates from the perineurium. Virtually it falls 
under the same considerations therefore. 

Lymphangioma originates from the axillary lymph- vessels 



Enchondroma of Chest-wall. 105 

and extends alongside the pectoralis major muscle. Some- 
times it proliferates considerably and may then reach even the 
mediastinum. Early removal is the best treatment. If on 
account of large size it cannot be extirpated in one seance, 
one part may be taken off first and another a few weeks after- 
ward. 

Enchondroma of sternum and ribs, while in fact of malignant 
character, on account of its frequent recurrence and its tendency 
to metastasis, is usually described among the benign because 
of its biological structure. It resembles chondrosarcoma, 
from which it is but difficultly distinguished. The seat of 
predilection is the body of the sternum, and the point of junc- 
tion between the bony and cartilaginous portions of the ribs. 
The size the enchondroma attains is often larger than that of the 
head of an adult. In such cases the tumor generally extends 
to the mediastinum. In the advanced stage the prognosis is 
unfavorable. The only rational therapy is early extirpation. 
The ribs, included in the tumorous mass, must be exsected. 
If the pleura participates, it has to be sacrificed, although the 
danger of pneumothorax should be thoroughly appreciated. 
In enchondroma sterni the pericardium may be invaded, so 
that its injury cannot be avoided. 

Osteoma of the chest-wall is rare. Its treatment consists 
in thorough extirpation. 

2. Malignant Growths. — Most malignant tumors of the 
sternum and ribs are sarcomatous. The chest- wall may be 
the seat of fibroma, osteoma, chondroma, myelosarcoma, and 
osteosarcoma. At the initial stage they may be confounded with 
tuberculous abscess or gumma. In the first instance aspiration 
by means of a large needle (because of the thickened pus) will 
clear the situation. If a gumma is suspected the good old 
diagnostic maxim, u Ex juvantibus et nocentibus," should be 
adhered to. The Rontgen method will also be of value in 
obscure cases, since it may determine how far the pleura 



106 Surgery of the Thoracic Wall. 

and lungs are involved and whether removal still offers any 
hope or benefit for the patient. The same may apply to 
far advanced cases of carcinoma mammas, which, thanks to 
the advances of surgery, are rarely seen at the present time. 

Tumors of the sternum are more frequently found during 
middle life. They excel by a predilection for sarcomatous 
degeneration, while the ribs are more frequently the seat of 
enchondromatous growths, which favor the infantile age more. 
The clinical characteristics of these tumors are their slow and 
painless growth. An injury often precedes their formation. 
The treatment of these neoplasms is entirely surgical. They 
must be removed as thoroughly as possible. Access is gained 
by obeying the principles of exploratory rib-resection (see 
section on this method, page*i88) after the tumor is exposed 
by a convex flap-incision. 

Except the tumor be small, the pleura will always be found 
adherent. Pneumothorax may consequently be expected, 
whereupon the operation might be done in the airless 
chamber. Haemorrhage is generally profuse. It will be treated 
best by proceeding very slowly and by frequently making use 
of temporary pressure-haemostasis. Sometimes adhesions to 
the lungs, the pericardium, or diaphragm must be divided. 
The Paquelin cautery should be used for division whenever 
possible. 

If thorough aseptic precautions were taken, the large 
wound is to be closed. In spite of the great risks taken, 
a number of good results are reported. The post-operative 
treatment of the field of operation by the Rontgen light is an 
important factor in the prevention of recurrence. 

Fig. 69 shows a case of myelosarcoma of the chest-wall, 
which, in spite of its extensive pleural adhesions, was success- 
fully removed. 

Primary carcinoma of the chest- wall is always of the type 
of the ulcus rodens. It is of a circumscribed character there- 



Carcinoma of Thoracic Wall. 



107 



fore. At the early stage it generally yields to energetic treat- 
ment by the Rontgen rays. At later stages the Rontgen 
treatment should be preceded by extensive extirpation with 
the scalpel. Whenever possible the defect left by the ex- 
tirpation should be covered by a healthy skin-flap. 




Fig. 60. — Myelosaecoma of Thoracic Wall. 



The large carcinomata found at the chest-wall are always 
of a secondary nature. The fibrous type of carcinoma mam- 
mae, characterized by its rapid growth, often surrounds the 
whole thoracic side like a harness {cancer en cuirasse). In 
such cases the prognosis is absolutely hopeless, the Rontgen 
therapy sometimes bringing temporary relief. 



108 Surgery of the Thoracic Wall. 

3. Hodgkin's disease (pseudoleukemia) shows its most 
characteristic external symptoms in the neck, the axillae, and 
the thoracic wall. As is well known, this most interesting 
disease bears a strong resemblance to sarcoma. Of the 
etiology and essential pathology of this obscure affection very 
little is known yet. Its characteristics are an enlargement 
of the lymphatic glands, lymphatic tissues forming in internal 
organs like the lungs, the liver, kidneys, spleen, and intestines. 
As a rule, the swelling begins in the glands* of the neck, one side 
of which is soon filled up by a mass of glands. Probably the 
nature of Hodgkin's disease is infectious, the specific effect of the 
alleged bacterium being caused by its predilection for lymphoid 
tissues. No permanent therapeutic results have been obtained 
so far, extirpation as well as administration of arsenic, bone- 
marrow, and toxine treatment having given only temporary 
benefit. 

Rontgen treatment tried recently has given much more satis- 
factory results. N. Senn 1 reported two cases in which a perfect 
cure was effected. One of the cases was that of a farmer of 
forty-five years whose glandular affection dated back a year. It 
had commenced in the cervical region almost simultaneously on 
both sides, and involved very extensively the glands of these locali- 
ties as well as the axillary and inguinal region. As Senn stated, 
there was a macular eruption of the skin all over the chest, back, 
and abdomen. The increased respiratory movements and 
dullness over the anterior mediastinum indicated the extension 
of the disease to the branchial and mediastinal glands. Spleen 
considerably enlarged. The patient received thirty-four treat- 
ments as follows : Right side of neck one minute, left side of 
neck one minute, neck from before backward one minute, each 
axilla one minute, neck from behind forward one minute, each 
groin one minute, spleen one minute. Daily sitting for the 
first ten days: 60 volts 8 amperes were used each day; distance 

x "New York Medical Journal," April 18, 1903. 



Hodgkin's Disease. 109 

of tube from surface 12 inches, a medium vacuum tube being 
used. The treatment was commenced on March 29, 1902. 
On April 7th, after ten treatments had been given, the glands 
had undergone a noticeable reduction in size. At this time 
the patient made complaint of an intense itching all over the 
chest, and a uniform redness made its appearance over the 
chest axillary regions. The voltage and amperage were 
reduced to 42 and 6 respectively. After the next six treatments 
the voltage was again reduced to 28, amperage remaining the 
same. April 15th: The itching became so severe that it kept 
the patient awake all night. The skin of the chest blistered. 
The skin of the neck, naturally very dark, turned dark brown. 
A 5 per cent, boric-acid- vaseline ointment, applied twice a 
day, relieved the itching 

From April 16th to 23d the exposures were limited to the 
neck, back, and groins, as the chest and axillae were the seat 
of quite an extensive burn. April 24th: All of the glands 
subjected to the Rontgen-ray treatment had nearly disappeared. 
The face and part of scalp exposed to action of the Rontgen 
rays are devoid of hair. Axillary and pubic hair has also dis- 
appeared. Skin of neck dark brown and blistered. The 
skin of the chest from the neck down to about 4 inches below 
the nipples exfoliated in several places. The nipples were 
very sore, discharging pus. The treatment was suspended, 
and the patient discharged from the hospital with instructions 
to continue the use of the salve and internal medicine. Two 
weeks later he returned to the hospital for more medicine, and 
expressed himself as feeling well. His appetite was good 
and he was able to attend to his duties. No enlarged glands 
could be discovered. No elevation of temperature. Breathing 
much improved. The dermatitis had improved. He re- 
turned a second time on August 1st, as he had recently noticed 
a slight enlargement of the cervical and axillary glands. He 
is feeling well and is able to attend to all of his business. 



no Surgery of the Thoracic Wall. 

Dermatitis has disappeared. Return of hair growth. Patient 
received daily ten treatments, 28 volts 6 amperes; each group 
of glands was exposed for two minutes at a distance of 12 inches, 





w 


f 1 


Wf M? 




'f^B 


If: 




* %. ^ 



Fig. 70. — Hodgkin's Disease (Neck, Axillae, and Supramammillary Regions). 

tube the same as before. The glands disappeared promptly. 
No return has taken place since, the patient being in perfect 
health, with the exception of a joint affection, which has no 
connection whatever with the pseudoleukaemic process. 



Rontgen Method in Hodgkin's Disease. m 

Senn maintains that there could be but very little doubt that 
the constitutional disturbances which followed the prolonged 
use of the Rontgen ray in his second case, and which set in 
simultaneously with the progressive diminution in the size of 




Fig. 71. — Hodgkin's Disease (Neck, Axilla, Anterior Surface of the Chest). 



the glands, were due to a toxaemia caused by the absorption 
of the products of degeneration of the pseudoleukaemic product. 
This toxic condition unquestionably was likewise the cause 
of the increased enlargement of the spleen noted after the 
second series of applications. This patient has been heard 



ii2 Surgery of the Thoracic Wall. 

from very recently, and it is believed that there are no indica- 
tions of the return of the disease, and he is considered in 
perfect health. 

Fig. 70 illustrates the case of a man of fifty-six years whose 
glandular affections began seven months before the picture was 
taken. At first the glands of the neck commenced to swell while 
the axillary glands showed an intumescence about three months 
later. Six months after the onset nodules alongside the pee- 
to ralis major muscle were noticed. The respiration was slightly 
accelerated, temperature normal, pulse-rate increased, and 
the spleen much enlarged. The general condition was poor, 
the patient being very anaemic. The patient received six 
exposures, each one lasting five minutes for each side. There 
was marked improvement, the patient in fact feeling so much 
better that he left the hospital. Fig. 71 illustrates the same 
affection in a man of fifty years, who noticed the first cervical 
nodules eleven months before the picture was taken. Three 
months later the axillary glands swelled and six months ago 
the inguinal region shared the same fate. There was no 
increase of the respiratory motions, the pulse and temperature 
being nearly normal. The spleen is enlarged during the 
last two months ; nodules from the size of a filbert to that of a 
small apple formed at the anterior surface of the chest. The 
patient was treated after the same principles, and improved 
considerably after seven applications. He is still under 
observation. 



(4) ECHINOCOCCUS OF THE CHEST-WALL. 

Echinococcus of the chest-wall generally develops in the 
muscular strata, as a soft and elastic mass, so that it may be 
confounded with lipoma at an early stage. Differentiation 
with abscess and other cystic tumors is sometimes difficult, 
but can always be obtained by the microscopic examination 



Echinococcus of Chest-wall. 113 

of the aspirated fluid of the cyst, in which the presence of the 
characteristic hooks settles the question. Sometimes they are 
detected after considerable search only. The presence of 
succinic acid also verifies the diagnosis. 

The therapy consists in extensive exposure and removal of 
the lining. The prognosis is favorable if these rigorous pro- 
cedures are resorted to early. 

Echinococcus of the chest-wall is rare. 



CHAPTER III. 

INTRATHORACIC DISEASES. 

A. PERICARDIUM. 

(i) ANATOMY OF THE PERICARDIUM. 

The pericardium (*ep{ rty zapstav, around the heart) is a 
membranous bag of a conical shape which surrounds the 
heart and the commencement of the large blood-vessels. It is 
inserted, so to say, between the two pleural sacs. In general the 
form of the pericardium is that of the heart, but its base is 
diverted downwards while its apex is diverted upwards. The 
base is tightly attached to the centrum tendineum of the dia- 
phragm. 

The pericardium consists of an internal layer which is serous 
and an external one which is fibrous, both membranes being 
intimately connected with each other. 

The relations of the serous layer to the heart are the same 
as those of the pleura to the lung. Consisting of a visceral as 
well as a parietal portion, it reflects itself on the inner peri- 
cardial surface. The dense fibrous layer mainly consists of 
the endothoracic fascia, and is attached to the posterior surface 
of the sternum by the ligamentum sterno-cardiacum superius 
and inferius. By this attachment the pressure of the heart upon 
the diaphragm is materially lessened. Above, the fibrous layer 
surrounds the large vessels which arise from the cardial basis. 

The pericardial arteries are derived from the descending 
thoracic aorta and from the internal mammary artery and its 
ramus musculo-phrenicus. 



Pericardium. 



"5 




Fig. 72. — Anterior Mediastinum — Heart Exposed after Dissection of Ante- 
rior Surface of Pericardium. — (Testut & Jacob.) 

1, Sternum; 2, second rib, with second sterno-costal junction; 3 and 4, sixth and seventh 
ribs; 5, M. triangularis sterni; 6, pericardium incised and unfolded; 7, anterior 
view of heart; 7', right auricle; 8, aorta; 8', preaortic fold; 9, arteria coronaria 
dextra; 10, arteria coronaria sinistra; n, arteria pulmonalis; 12, vena cava 
superior; 13 and 13', right and left venous brachiocephalic trunks; 14, arterial 
brachiocephalic trunk; 15, veins of thymus; 16 and 16', right and left lungs 
from without; 17, internal mammary vessels; 18, intercostal vessels; 19, pec- 
toralis major muscle; 20, subpectoral adipo-cellular tissue. 



n6 Intrathoracic Diseases. 

Since the heart does not fill up its bag, the vacant space is 
occupied by a serous fluid, called liquor pericardii, which 
amounts to about one-half ounce. 



(2) INJURIES OF THE PERICARDIUM. 

Isolated injuries of the pericardium are regarded as rare, 
Fischer having collected 51 cases in literature. Still it must 
be remembered that in a number of cases the pericardium 
is injured, but, the symptoms being insignificant and the 
course favorable, the diagnosis is not made. Whenever 
there is an effusion in the pericardium the symptoms be- 
come so severe that they cannot be misinterpreted, especially 
when the heart becomes irregular and dyspnoea sets in. 
The cardiac murmur is hardly perceptible then and is mixed 
with friction-sounds. The treatment corresponds with that 
of the penetrating wounds of the chest in the beginning (see 
page 83). If the symptoms become aggravating, the pres- 
ence of haemopericardium being assumed, pericardiotomy is 
indicated. The writer had repeated opportunities to convince 
himself of the life-saving effect of this unduly neglected opera- 
tion. 

(3) ASPIRATION OF THE PERICARDIUM. 

In cases of haemopericardium aspiration may be tried before 
pericardiotomy is resorted to. The same should be done in 
cases of suspected hydropericardium, for diagnostic as well as 
for curative purposes. A trocar should never be used for this 
operation, a Dieulafoy aspirator of medium size to which a 
thin needle is attached being recommended. The principles of 
asepsis, emphasized on page 61, must be rigidly observed. 

The needle should be introduced in the fifth intercostal space 
on the left, close to the sternal margin (Fig. 73). The direction 
of the needle should, however, not be rectangular to the sternal 



Aspiration of Pericardium. 117 




Fig. 73. — Pericardial Aspiration. 




Diaphragm 



Fig. 74. — Large Pericardial Exudate. — (After Curschmann.) 



n8 Intrathoracic Diseases. 

surface, but obliquely downward and inward in order to avoid 
interference with the heart (see Fig. 73). 

In the presence of a large effusion, as illustrated by 
Fig. 74, the exudate may still be reached two inches from the 
sternal margin, but it is always safer to stick to the immediate 
vicinity of the latter. 

If decomposed serum or pus is aspirated, a broad opening 
which exposes the pericardial sac thoroughly should be made at 
once. 

(4) PERICARDIOTOMY. 

In the event just mentioned pericardiotomy is directly life- 
saving. Pus formation may follow an injury of the pericardium 
as well as an inflammatory process. The writer observed a 
large pyopericardium in a boy of fifteen years after the forma- 
tion of a retrosternal abscess, due to tuberculosis of sternum 
and ribs, which perforated into the pericardial sac. Recovery 
took place after extensive resection of a portion of the sternum 
and of four ribs. 

In haemopericardium pericardiotomy is usually preferable 
to aspiration. 

The conditio sine qua non of this operation is the preliminary 
resection of two or more ribs. In cases of injury the fifth costal 
cartilage is selected, while in inflammatory processes a wide 
area is to be exposed for the beginning of the operation. 

The fifth cartilage is exposed by making an incision of four 
inches in length, which begins at the centre of the sternum and 
extends alongside and over the middle of that cartilage. After 
its connection with the sternum is severed by a strong scalpel, it 
is freed from its posterior attachments and lifted by the aid of the 
rib-embracer. Now it is easy to push it outward and upward, 
so that it can be divided at its junction with the rib. By this 
procedure the fourth and fifth intercostal spaces are exposed. 
In most cases the additional exscction of the fourth and sixth 
cartilages is indicated. 



Dividing the Pericardium. 



119 



By appreciating that the pleural sac is but slightly attached 
to the pericardium while its connection with the triangular 
muscle is much more intimate, it will be realized that this 
muscle demands great attention. First of all, it is carefully 
dissected and then drawn outward in order to permit of push- 
ing back the pleura. Thus the anterior aspect of the pericar- 
dium is freed. 

The serrated insertions of the triangularis muscle are severed 
from the posterior surface of the sternum by introducing a 




Fig. 75. — Pericardiotomy. — (Lejars.) 
Skin and muscle incised in the shape of an H, the fifth costal cartilage divided and re- 
tracted outwardly. The anterior pericardial membrane is seized with two Pean 
forceps and pulled forward and upward. 

grooved director underneath the sternal margin and freeing the 
tendinous fibres from the periosteum. Then the index-finger 
finishes the manoeuvre by pushing the tissues in front of the 
pericardium aside, where they are held by a blunt retractor. 
If the pericardial membrane is seized by two forceps, it is 
pulled forward and upward so that it can be incised from below 
upward, thus avoiding any possible injury of the heart (Fig. 75). 
In sticking close to the sternal margin the mammaria interna 
cannot be interfered with (compare Fig. 27). In returning 



120 Intrathoracic Diseases. 

the pericardium the serous surfaces must be brought into apposi- 
tion. As a rule, iodoform gauze drainage should be resorted to 
during after-treatment. 

B. HEART. 

(i) ANATOMY OF THE HEART. 

The heart, a hollow, conical, muscular body, is the central 
organ of the circulatory system and is situated directly behind 
the sternum between the two concave surfaces of the lungs. 

Being placed obliquely in the thoracic cavity, it turns 
its base to the right in the upward and backward direction, so 
that it corresponds to the space situated between the fifth and 
sixth dorsal vertebrae. The direction of the apex is forward and 
downward to the left and corresponds to the interval between the 
cartilage of the fifth and sixth ribs, about one and one-half 
inches below the left nipple. As a whole, the position of the heart 
is such that its longitudinal diameter forms an angle of 50 degrees 
with the vertical diameter of the thorax. In the adult it 
measures five inches in length, three and a half in breadth, and 
two and one-half inches in thickness. In the male it weighs 
between ten and twelve ounces, while in the female the weight 
amounts to from eight to ten only. The anterior surface has a 
round and convex shape and shows a longitudinal oblique 
furrow which bends around the apex, slightly deviating to the 
right to return to the base at the posterior surface. This groove 
is called the sulcus longitudinalis and is the exterior expression 
of the longitudinal septum in the cavity of the heart. It is 
rectangularly crossed by a transverse groove called sulcus 
circularis or coronalis, which is marked, however, at the poste- 
rior surface only, while the anterior surface is covered by the 
arteria aorta and pulmonalis. Thus the heart is divided into 
halves by a septum which corresponds to the sulcus longitudi- 
nalis. Each of these halves consists of a smaller and a larger 



Arteries of the Heart. 121 

cavity, called atrium and ventricle respectively. To each atrium 
an appendage, called the auricle, is attached, which is curved 
forward and inward. The right half receives in its auricle the 
venous blood by the superior and inferior vena cava and the coro- 
nary sinus. From there the blood reaches the lungs through the 
pulmonary artery, where it is made arterial, to be returned to the 
left auricle by the route of the vena pulmonalis. Thence it 
reaches the left ventricle again, to be sent through the body by 
the aortic route. 

The arteries of the heart are immense vasa vasorum. 
They are the right and left coronary arteries and arise from 
the ascending aorta within the cavum pericardii. The coro- 
naria dextra or posterior passes forward in the sulcus circu- 
laris of the anterior surface of the heart to the right cardial 
border and then turns around to the posterior surface of the 
heart, in which course it runs alongside the auriculo-ventricular 
groove. 

The coronaria sinistra or anterior, which is not as well 
developed as its fellow, winds around the left cardial border in 
the sulcus circularis. Then it divides into two branches, of which 
one passes to the apex in the sulcus longitudinalis anterior. 
The other branch, called the transverse, passes over to the 
posterior surface of the heart in the auriculo-ventricular groove. 

It is important to know that the coronary arteries show a 
greater tendency to sclerotic degeneration than any other artery 
in the body. 

As far as the structure of the heart muscle is concerned, 
an outer and inner membranous layer, besides a muscular 
one (myocardium), which is situated between them, are to 
be distinguished. The outer layer, which belongs to the 
pericardial cavum, is thin and smooth and contains a 
large number of elastic fibres. By short connective tissue it is 
intimately connected with the muscular structure. The inner 
lining of the heart, called the endocardium, is a thin, smooth, 



122 Intrathoracic Diseases. 

and transparent membrane, which consists merely of elastic 
fibres lined with pavement epithelium. 

The special description of the ventricles, etc., is not a sur- 
gical subject. 

0) INJURIES OF THE HEART. 

Injuries of the heart used to be regarded as fatal, still modern 
surgery reports a number of recoveries contradicting the old 
doctrine that wounds of the heart would invariably lead to 
death. Those patients who do not succumb immediately, as a 
rule, become unconscious for a while, show great anaemia, the 
respiration becomes superficial and rapid, the pulse small, fre- 
quent, and irregular, the apex-beat disappears, and the alae nasi 
move rapidly, as in severe peritonitis. Others, however, may 
not show any signs which would point to the severe character 
of the injury at the moment it is inflicted, and may even be 
able to walk some distance, so that the grave nature of the wound 
escapes attention until the further course proves it. The 
marked feeling of anxiety is one of the most characteristic 
signs of heart-injury. 

The continuance of the haemorrhage may terminate life 
in a few hours then, but sometimes the haemorrhage stops, 
the weak action of the heart being a favoring moment. After 
the danger of shock and haemorrhage is over, pericarditis may 
still threaten the patient's life. Even after recovery pericardial 
adhesions, dilatation of the right and hypertrophy of the left 
ventricle may be a source of great disturbance. Sometimes 
bullets become encysted in the heart, causing little trouble. 
With the increased knowledge gained by the Rontgen rays, the 
statistics will doubtless show more cases of this kind. (See 
author's case, in which the heart was wounded, the bullet being 
lodged in the pericardial cavum, page 72.) 

Treatment. — The treatment is symptomatic. As the 
weak contractions of the heart favor haemostasis, any dis- 



Treatment of Injury of Heart. 



123 



turbance should be avoided. If possible, the patient should 
not be moved for at least a few hours. Transportation must 
be undertaken with great care. Morphine injections in com- 
bination with saline infusions are the conditio sine qua non. 
Nourishment should consist exclusively in milk diet. Later 




Fig. 76. — Medio-sagittal Section of Anterior Pericardium and Routes of 
Access. — {Testut &° Jacob.) 

1, Pericardium; 2, heart; 3, sternum; 4, pleura; 5, lungs; 6, opening presenting 
xiphoid process, and on a level with it the subcutaneous and prsepericardiac tis- 
sue; 7, xiphoid process; 8, diaphragm; 9, parietal peritoneum; 10, subperitoneal 
cellular tissue; 11, anterior abdominal surface; 12, transverse colon; 13, liver; 
14, transverse mesocolon; a, route of access to the anterior thoracic region; 
b, to the xiphoid process; c, abdominal transdiaphragmatic route. 



digitalis and hypodermatic saline infusions (Fig. 81) may be 
administered. 

If the symptoms of compression prevail, the heart must 
be exposed. For this purpose an incision is made over 



124 



Intrathoracic Diseases. 



the fifth rib extending from the left sternal margin to 
the anterior axillary line. After the corresponding rib- 
portion is exsected, the exposed area is carefully ex- 
plored. If access does not prove to be easy then, parts 
of the sternum or the fourth rib are removed in addition. 
The ribs do not necessarily need to be resected in their totality, 
but may be folded up at their sternal junction like a bone flap 
of the skull. The apex is secured with a strong silk 
suture, so that it can be pressed against the thoracic wall, 
Fortunately most wounds of the heart concern its anterior sur- 
face, so that they are easily found. The right half of the heart is 




Fig. 77. — Suture of Wound of Ventricle, the Needle being Conducted 
through the heart-muscle and the flrst suture ends utilized as a 
Traction-suture. — (Lejars.) 

best sutured during diastole and the left during systole, the 
material being catgut (Fig. 77). 

According to Fischer, the percentage of recoveries is not 
higher than 10. It seems to the author that it amounts to about 
35. The best chances are offered by the wounds of the anterior 
surface. The ligature of the arteria coronaria was carried out 
successfully by Tassi. The wounds of the large thoracic 
vessels are hardly the object of surgical interference since the 
injured succumb immediately after the injury. Some sur- 
vive it for a time. As a warning it may be reported that in 
the author's practice the innominate of a strong man of 



Wounds of Diaphragm. 125 

thirty-four years was divided by a pocket-knife which 
had entered the subclavicular space, leaving but a small 
opening there. The patient being under the influence of 
liquor and the wound yielding but a few drops of blood, the 
somnolent condition of the patient was attributed to his 
intoxication, so that an ambulance surgeon, who saw him an 
hour afterward, declared his condition to be fairly normal. Two 
hours after the injury the patient was dead, the family not 
detecting the true nature of his " stupor" until three hours 
thereafter. 

Wounds of the diaphragm are but rarely recognized. 
Sometimes there are no symptoms at all pointing to this injury, 
sometimes there is protrusion of the thorax combined with 
sinking in of the abdomen. The heart is displaced and 
dyspnoea develops. Percussion reveals tympanitic sounds. 
In contradistinction to the intrathoracic injuries described 
above there is distention of the abdomen and symptoms of in- 
carceration. The treatment is generally without avail except 
in the case of incarceration, when laparotomy in combination 
with suture of the diaphragm is indicated. 

C. PLEURA. 

(1) ANATOMY OF THE PLEURA. 

The thoracic cavity harbors three serous sacs, of which 
two are in pairs. They are called the pleurae and serve the 
purpose of enclosing both lungs as far as their roots. The 
other serous sac, called the pericardium, is single and, as de- 
scribed above, encloses the heart and is situated between the 
two pleurae. Each pleura is reflected upon the interior thoracic 
surface, so that, in fact, it represents two membranes. The one 
investing the visceral surface is termed pulmonal pleura, and 
the other, investing the interior surface of the chest-wall, is called 
the parietal pleura. Under normal conditions these two mem- 



126 Intrathoracic Diseases. 

branous layers are in close contact. Only when the cavity is 
exposed, the lungs by their elasticity collapse and a hollow 
space forms between the pleurae so that a pleural cavity can be 
spoken of. The right and left pleurae not meeting in the 
median line of the thoracic cavity, it is evident that a space is 
left there. This is called the mediastinum, which is divided 
into an upper portion which is above the pericardium, and a 
lower which is below the upper level of the pericardium. 

The upper portion of the mediastinum is situated above 
the upper pericardial level, between the sternal manubrium 
anteriorly and the upper dorsal vertebrae posteriorly. Below 
it is bounded by a line drawn from the union of manubrium 
and gladiolus of the sternum to the lower portion of the body 
of the fourth dorsal vertebra. The anterior portion of the 
mediastinum is bounded by the sternum in front, the peri- 
cardium behind, and the pleura on both sides. The posterior 
mediastinum, a triangular and irregular space, is bounded by 
the pericardium and the roots of the lungs in front, by the lower 
border of the fourth vertebra behind and the pleura on both 
sides. The middle mediastinum is situated between the two 
latter. 

Of the parietal pleura three different parts are distinguished, 
viz., the external (costal), the internal (mediastinal), and the 
inferior (phrenic). The costal part invests the ribs as well as 
the costal cartilages, the contents of all the intercostal spaces, 
the arteria mammaria interna, and the triangularis sterni 
muscle. It is furthermore in relation to the subcostal muscles, 
to which it attaches itself by the fascia endothoracica. 

The phrenic part rests, as its name indicates, on the 
diaphragm, while the mediastinal portion is in relation to the 
pericardial sac, the nervus phrenicus, and the vessels which 
accompany it, on both sides. On the left side it is in relation 
to the descending and transverse aortic portions, the left ar- 
teria carotis and subclavia, the ductus thoracicus, the left nervus 



Mediastinum. 



127 




Fig. 78. — Mediastinum — Lateral View after Dissection of the Pulmonary 
Pedicle, the Pleura Remaining in Situ. — (Testut & Jacob.) 

1, Integument and subcutaneous tissue; 2, dorsal muscles; 3 and 3', first and ninth 
ribs; 4, intercostal muscles; 5, intercostal vessels; 6, pectoralis major; 7, clavicle; 
8, subclavian muscle; 9, subclavian artery and vein; 10, brachial plexus; 11, 
costal pleura; 12, mediastinal pleura; 13, pleura dissected from the pedicle; 
14, left bronchus; 16, left branch of the pulmonary artery; 17 and 17', left pul- 
monary veins; 18, pericardium seen in the depth; 19, thoracic aorta. 



128 Intrathoracic Diseases. 

vagus, and the left vena intercostalis superior. On the right side 
it bears relation to the aorta ascendens, the vena cava superior, 
the vena azygos major, the arteria innominata, the vena in- 
nominata dextra, and the right nervus vagus. 



(2) DISEASES OF THE PLEURA. 

The diseases of the pleura are with a very few exceptions of 
a secondary nature, as they represent either a part of a general 
infection or are transmitted from a disease of a neighboring 
organ. The primary source may be healed, however, when 
the secondary affection begins, so, for instance, a pneumonia 
may have disappeared while a pleural effusion establishes 
itself. The main affections of the pleura which deserve sur- 
gical consideration are the effusions and the tumors. The 
various fluids in the pleural sac are either transudations (hy- 
drothorax) or serous (serothorax), purulent (pyothorax), 
bloody (haemothorax), and sero-haemorrhagic (sero-haemo- 
thorax), or chylous effusions (chylothorax) . 

All effusions cause dyspnoea. If extensive, cyanosis besides 
a frequent pulse is marked. The diseased thoracic walls are dis- 
tended and do not participate in the respiratory excursions. 
Percussion shows dullness, and marked displacement of the 
heart. Auscultation proves absence of vocal fremitus and 
weakened breathing sounds. Any infectious disease of the 
lungs may be followed by the formation of an effusion. 
Tumors of the lungs, like carcinoma, carcinoma oesophagi, in- 
flammation of the mediastinum or of the bronchial glands, pneu- 
monia, tuberculosis, abscess, gangrene, and influenza may be 
responsible for the development of pleural effusion. As will be 
seen on page 257, even subphrenic abscess produced by perfor- 
ation of the stomach, liver-abscesses, cholangitis, and appendi- 
citis may lead to secondary pyothorax. 



Serous Effusions. 129 

(3) SEROTHORAX (SEROUS EXUDATIVE PLEURITIS). 

The contents of a pure serothorax consist of a clear, sterile, 
aqueous liquid containing a large amount of albumin. There 
are but a few cellular elements and no bacteria, the latter 
circumstance explaining why there is no tendency to suppu- 
ration. 

The aetiology of simple serothorax is still under dispute. 
Most cases are of a secondary nature, the idiopathic type being 
rare. Some investigators believe that tuberculosis of the 
pleura or of the lungs causes secondary pleural exudation most 
frequently. Others claim that the inhalation of coal particles 
and dust would be the exciting moment. 

If this be true, this kind of pleuritis would be a typical 
idiopathic form. How much consideration the old theory 
of a cold deserves is difficult to prove. There can be no 
doubt that a rapid change of temperature produces vaso- 
motoric disturbances, which pave the way for bacterial inva- 
sion, rendering the tissues a favorable soil, so to say, for the 
development of micro-organisms. 

Most purulent effusions are preceded by a serous stage ; but 
even then they contain a large number of leucocytes. When 
examined microscopically bacteria, especially staphylococci, 
streptococci, and pneumococci, are found, while a simple serous 
effusion contains a pure and clear liquid in which no bacteria 
can be detected. 

According to Fiedler, idiopathic pleuritis may also be 
caused by the essential causative factors of articular rheuma- 
tism. 

The mechanical changes caused in the thoracic cavity by 
the formation of an effusion are enormous, the space for the 
intrathoracic organs being considerably reduced. As indicated 
by Fig. 79, B, costal and pulmonal pleura are widely kept apart 
by the presence of a large exudate which compresses the 



I 3° 



Intrathoracic Diseases. 



atelectatic lung to a minimum. The chest- wall is naturally dis- 
tended so that the diseased thoracic half shows a larger circum- 
ference than the normal side and the sternum is shifted toward 
the diseased sphere. Respiratory motions are impossible, the 
whole side being fixed in extreme inspiration and all air in the 
lung, which is generally pushed against the spinal column, 
being evacuated completely. The heart becomes displaced 
toward the opposite side. (Esophagus and descending aorta 






Fig. 79. — Normal and Diseased Pleura (Schematic). — {Testut & Jacob.) 
A, Normal pleural cavity; B, pleural cavity entirely filled by effusion; C, pleural 
cavity partially compressed by encysted effusions; 1, parietal portion of the 
pleura; i f , visceral membrane of pleura; 2, interlobular fissure; 3, costo-dia- 
phragmatic sinus; 4, thoracic wall; 5, lung; 6, diaphragm; 7, liver; 8, total 
pleuritis; 9, encysted mediastinal pleuritis; 10, encysted interlobar pleuritis; n, 
adhesions uniting visceral pleura to the lung and the parietal pleura; 12, small 
encysted effusion; 13, encysted diaphragmatic pleuritis. 

are also shifted aside. The diaphragm forms a concavity where 
it showed a convexity under normal circumstances, and conse- 
quently the kidneys are also pressed downward. On the left 
side the spleen, on the right the liver, share the same fate. It 
is evident that the symptoms caused by these conditions as- 
sume an alarming character, especially the disturbances of cir- 
culation being extremely grave. In cases of small extent, espe- 



Aspiratory Puncture. 131 

cially where the effusions are encysted (Fig. 79, C), the symp- 
toms of serothorax are mild pain, which, as a rule, is localized, 
slight dyspnoea, and moderate fever. Such small effusions 
disappear under immobilization in bed, diet, Priessnitz applica- 
tions, and large doses of podium salicylate in combination 
with small amounts of morphine. Later iodide of potassium 
in moderate doses is recommendable. 

But if pressure-symptoms indicate that the size of the 
effusion becomes considerable, aspiration must be resorted to. 
In case of re-accumulation the procedure may be repeated, 
but if this should occur several times, rib-resection and drainage 
are indicated. If, as it sometimes occurs, bacteriological 
examination should prove the presence of streptococci in an 
apparently clear serous exudate, the resection treatment should 
be undertaken without delay, since it can with certainty be 
expected that the morphological appearance of an effusion of 
this kind will soon assume a purulent character. 



(4) ASPIRATORY PUNCTURE. 

Aspiration is a surgical procedure and must therefore be 
preceded by the most rigid aseptic precautions. (As to the 
principle of asepsis see page 62.) 

Aside from the general rules regarding asepsis of the skin, 
the following points should be considered: No matter how 
well the integument is sterilized, the deep skin bacteria, which 
are sheltered by the follicles of the integument, cannot be 
destroyed by ordinary means of disinfection. Still, a great 
deal can be done to lessen the danger of infection by this 
source. Fortunately, we possess a permeating disinfectant 
in the tincture of iodine, which reaches the bacterial shelter — 
the glands. Bacteriological experiments as well as clinical 
experience have shown that, if the region to be punctured is 
first painted with iodine tincture, a sterilized needle in sterilized 



132 



Intrathoracic Diseases. 



hands will not carry bacteria which will develop in the cavity. 
Intracutaneous bacteria are not destroyed by the tincture, but 
they will be so affected that their power of development is 
inhibited. 

Aspiration is one of the most important diagnostic means 
and should be employed as soon as 
there is the slightest suspicion of the 
presence of an effusion. The syringe 
selected for the purpose should be 
fairly large and the needle strong, 
since any unfortunate motion of the 
patient might break a thin one. 
One of the best aspiratory instru- 
ments is the one illustrated by Fig. 
80. The author constructed a large 
aspirator provided with a heavy 
stand after this principle (Fig. 82). 
For larger effusions the apparatus of 
Dieulafoy is recommended. Trocars 
should never be employed for the 
evacuation of intrathoracic fluids. 

Aspiration is best performed in the 

recumbent position. It is true that 

the sitting posture is more comfortable 

for the patient, but is apt to produce 

sudden anaemia of the brain, which 

may prove to be fatal sometimes. 

The needle must be introduced at 

right angles with the rib selected, 

-aspiratory syringe, the posterior axillary line in the 

sixth intercostal space being the most 

suitable point in the great majority of cases (Fig. 82). The 

submammary region is the area most favored for subcutaneous 

infusion of saline solutions in cases of shock and excessive 




Exploratory Pleurotomy. 



*33 



anaemia. The preparations for this operation- -and an oper- 
ation it is — should be made according to the principles de- 
scribed above, thorough asepsis being imperative. As to the 
modus operandi , see Fig. 81. 




FlG. 8l. — SUBMAMMILLARY INFUSION. 



(5) EXPLORATORY PLEUROTOMY. 

Exploratory pleurotomy was advised and performed first by 
the author, * and later on recommended by Tuffier . 2 The experi- 
ence that in spite of the most thorough examination and observa- 
tion a correct diagnosis could not be made sometimes, and that 
even repeated exploratory puncture did not reveal the true nature 

1 "Exploratory Pleurotomy and Resection of Costal Pleura," New York Medical 
Journal, Mar. 15, 1895. 

2 Turner: " Chirurgie du pneumon," XII International Congress, Moscow, 1S07. 



134 Intrathoracic Diseases. 

of the condition, induced the author to substitute exploratory 
incision for exploratory puncture in doubtful cases. In the 
section on pyo thorax (page 147) reference is made to a number 
of cases of pyothorax in which the presence of fibrous masses 
or of thickened or cheesy pus prevented their aspiration. The 
symptoms of effusion (compression, dyspnoea, dullness, weak- 
ened respiratory sounds) may be present after pleuro-pneumo- 
nia of long standing, and still aspiration would not yield any 
fluid. The question arises then whether after absorption of 
the fluid the pleural walls became thickened, or whether cheesy 
masses were left. The marked feeling of resistance expe- 
rienced while pushing the needle into the pleural tissue would 
indicate the fibrous character of the pleura. Still it must be 
considered that both conditions might be combined. If 
cheesy masses were present, their absorption would by no 
means be desirable, since this would predispose to tuberculosis. 
It is true that the acute onset of the disease would exclude the 
possibility of the presence of a neoplasm like carcinoma, 
sarcoma, or lymphoma, and that differentiation from sub- 
pleural abscess or echinococcus of the lungs would not be 
difficult. Still the question of tuberculosis could not be settled 
with certainty, since the sputa as well as the fragmentary drop 
gained by the dry aspiration may not show any tubercle bacilli, 
in spite of the presence of tuberculosis. The fact that from 
cases of pleuritis, in which the tuberculous character had been 
diagnosticated by other means, portions of the effusion were 
aspirated and injected into the peritoneal cavities of rabbits 
without producing any symptoms of tuberculous infection, 
proves the uncertainty of the negative result. 

As to differentiation from lung abscess see the section on 
that subject. 

The present status of the Rontgen method does not war- 
rant any reliable points of differentiation in this connection. 
Other means of information except the exploratory operation 



Decortication. 135 

can therefore be relied upon but rarely. It is a strange phenom- 
enon that there is a certain aversion, or rather timidity, in regard 
to this procedure. While in obscure abdominal conditions 
no surgeon hesitates to open the peritoneum, why should the 
pleura be a noli me tangere? All that can be feared in an 
incision of this kind is the formation of pneumothorax. But 
this accident would hardly occur in pleuritis of long standing, 
where the presence of adhesions would prevent unintentional 
opening of the thorax. Under strict aseptic precautions even 
this accident, however, would not necessarily be dangerous, 
since pneumothorax would disappear soon after the wound 
closed, the lungs then expanding readily. The author has, 
for instance, met with dangerous symptoms in his cases of 
subphrenic abscess where, after resection of a rib, the pleural 
sac was opened before being incised through the diaphragm. 
In the case of a very much emaciated patient the symptoms 
of shock became evident as soon as, after opening of the pleura, 
air rushed into the pleural cavity, so that incision of the sub- 
phrenic abscess was deferred until the following day, where- 
after the patient made a good recovery. 

The modus operandi consists in making an incision which 
extends over the rib covering the centre of the dull area. A 
rib-portion, four to five inches in length, is resected subperi- 
osteally, and the posterior portion of the periosteum divided 
then, so that the costal pleura comes into view. Careful dis- 
section reveals the presence of fibrous tissue, which is cut off 
by using the knife on the flat upon the pleura in the manner 
in which it is held during the process of shaving off the integ- 
umental flaps in skin-grafting. Sometimes some of the tissue 
is found to be cartilaginous or even calcareous, so that the 
knife produces a grating sound. After the flat incisions are 
repeated about a dozen times, thus constantly removing pleural 
tissue, a point of softer consistence is reached. 

Now a flat probe is introduced in order to ascertain whether 



136 Intrathoracic Diseases. 

the inner surface of the costal and the external surface of the 
pulmonal pleura are loosely attached to each other by adhe- 
sions. By pushing the probe farther back it is easy to lift 
the posterior surface of the costal pleura from the correspond- 
ing anterior surface of the pulmonal pleura by tearing the 
adhesions. If the fibrous condition of the costal pleura is 
found to extend farther, more ribs are removed in propor- 
tion. Then, by lifting up the costal from the pulmonal 
pleura, and after having introduced a blunt elevator through 
the incision in the costal pleura, the degenerated costal pleura 
is exsected. Cheesy masses are, of course, removed with some 
tissue. The edges of the wound are united by a continuous 
silk suture, a few sterilized wicks being left in each corner of 
the wound. Then, by means of sterile gauze and of a large 
piece of absorbent moss-board, compression is exerted upon 
the resected area. 

Even if only a portion of the thickened pleura is resected, 
compression is considerably relieved, as is evident from the 
disappearance of the dyspnoea in the author's cases. 

If performed under strict aseptic precautions, the risks 
of exploratory pleurotomy are small. Operations of this 
nature can be carried out with more safety if the air-chamber 
constructed by Sauerbruch is used. This ingenious inven- 
tion eliminates the possibility of pneumothorax in intrathoracic 
operations by excluding the atmospheric pressure during the 
operative procedure, thus preventing collapsing of the lungs 
after being opened to the air. In a lower animal Sauerbruch 
opened the thorax on both sides, and removed sternum and 
ribs without seeing the respiration interfered with in the slight- 
est degree. The Sauerbruch chamber is air-tight. Its size 
permits of the presence of surgeon, assistant, patient, and 
operating table. The head of the animal may project outside, 
while a rubber cuff is tightened around its neck. Regulation 
of the air-pressure is done by an air-pump, a valve in its wall 



Pyothorax. 137 

permitting the entrance of a sufficient amount of air to keep 
up continuous negative pressure inside the chamber. Von 
Mikulicz and his assistant, who did some work inside of the 
air-chamber for an hour, did not suffer any discomfort. The 
chamber is composed of boards, which are lined with tin, 
soldered at the corners. The roof is made of glass. 



PYOTHORAX (EMPYEMA PLEURA). 

The treatment of pyothorax dates back to the remotest 
antiquity, and marks one of the most brilliant eras of pre- 
Hippocratic surgery. It is reported that Euryphon of Cnidos 
saved the life of Cinesias by opening the chest-wall with the 
actual cautery. In the seventh book of the "History of 
Nature," Pliny describes the case of Pharaeus, who, after 
having been given up by his physicians, sought death on the 
battle-field, but when thrust in the chest by a spearman, pus 
escaped from the wound, and the seeker of death recovered, 
having been cured by the weapon of his enemy. 

There can be no doubt that thoracotomy for pyothorax 
was performed by the great master Hippocrates. A study 
of his book, "De Morbis Popularibus, " will convince the 
most skeptical that long before this the opening of the chest- 
wall was an established operation, the indications for which 
were well defined. These could be brought to such a degree 
of precision only as a result of the very frequent and extensive 
employment of different operative procedures, as free open- 
ing by the knife, the actual cautery, and the trephining and 
exsection of a rib. Hippocrates laid great stress upon wash- 
ing the patients frequently and with very warm water be- 
fore the operation was performed. Does not this extra- 
ordinary cleanliness appear like the dawn of aseptic principles ? 
Is it not an explanation of the operations performed at that 
early time with such signal success that some are inclined 



i3 8 Intrathoracic Diseases. 

to doubt the authenticity of the records ? In this connection, 
the modern surgeon may recall the frequent washings by the 
Hebrews — a religio-physiological rite ordained by Moses, who 
doubtless was one of the greatest judges of human requirements. 

The diagnosis of pyothorax, as described in Hippocrates's 
book, "De Morbis Popularibus, " is based upon the auscul- 
tation of a " splashing sound, while the patient was shaken," 
and "a noise similar to the one to be heard when vinegar 
boils. Furthermore the character of the respiration, the 
position of the patient, the eventual swelling of the diseased 
side, the fever, the pain, and the hydrops which was pres- 
ent now and then, were considered." 

In reference to the technic of the operation, the advice is 
given "to prepare the patient, fifteen days after the onset 
of the disease, by washing him first very thoroughly with 
warm water." Then the patient had to be placed upon a 
chair. After his hands were tightened, he was shaken by 
his shoulders, in order to ascertain, by the perception of the 
splashing sounds, which side was the diseased one. The 
incision was made far down on the most dependent part 
of the pleural cavity. After the skin was divided with 
a sword-like knife {jiayaipiq anqftoeidyq), surrounded by an ad- 
hesive mass up to three-quarters of an inch from its tip, a 
long, thin scalpel (hceiza d*upeUi faodijeaq paxei) was thrust into 
the pus cavity. As soon as a part of the pus was discharged the 
wound was closed by a piece of raw linen, to which a strong 
thread was attached. The cavity was evacuated once every day. 
After the tenth day warm wine and oil were infused every morn- 
ing and evening. If the pus was of a watery and sticky char- 
acter and also of considerable quantity, a tube of tin was 
introduced and shortened gradually according to the prog- 
ress of the healing process. When the left side was concerned, 
the prognosis was better than when it was the right one. 
In Article XLV ("De Morbis," II) the following prognostic 
hints are given: 



The Asepsis of Hippocrates. 139 

"If the pus is white, clean, and slightly bloody, a cure 
is effected in the majority of cases. But if it be thick, green- 
ish-yellow, and malodorous, a fatal outcome is to be expected." 

There can be no doubt that, based upon such perfected 
diagnostic means, thoracotomy was performed frequently 
and successfully during the splendid Hippocratic era, and 
that most of its admirable knowledge was lost during the 
twenty- three centuries that have followed. 

A slight indication of what the medical world has lost 
of the immense knowledge of the school of Cos, and how 
advanced the technics of Roman surgery must have been, 
may be gleaned from a visit to Pompeii. On the repeated 
visits of the author to this most interesting place it struck him 
that the peculiar construction of the "house of the surgeon," so 
well known to the readers of Bulwer's "Last Days of Pompeii," 
pointed to more or less developed principles of asepsis. ■ The 
streams of water constantly flowing through the streets of 
Roman cities were certainly adapted to remove pathogenic 
bacteria, or at least much of their favorable soil of development, 
and the large number of small wells in the "house of the surgeon" 
suggests that the wounded as well as the instruments and 
dressings were subjected to a very thorough cleaning before 
and during operation. This would be in harmony with the 
advice of Hippocrates to frequently wash the patient before 
performing an operation. From these facts we can fully 
understand why these old masters with their fine art of diagnosis 
and with their powerful weapon "cleanliness" have obtained 
better results than the surgeon of later years, who, after 
washing his hands superficially in non-sterile water, went 
directly from an autopsy to the operating-room. There, alas! 
the masterpiece of anatomical demonstration was repeated 
on the living patient, who was thus frequently turned into a 
premature specimen for the autopsy-room. 

Interesting witnesses of this grand era are the perfect 



140 Intrathoracic Diseases. 

instruments made of steel and bronze which, after being exca- 
vated at Herculaneum and Pompeii, are exhibited now in 
the Vatican at Rome and in the Museum at Naples. 

Celsus and Galen repeated the doctrines of Hippocrates, 
but later on the whole subject dropped into entire oblivion. 
During the Middle Ages thoracotomy was mentioned and 
performed by Ambroise Pare, Fabricius ab Aquapendente, 
and Jerome Goulu. But this was done only sporadically, 
Heister, the greatest German surgeon of the eighteenth cen- 
tury, mentioning the operation as a most unsatisfactory one, 
and Corvisart, the celebrated surgeon of Napoleon, holding 
that thoracotomy always accelerated death. Thus, it is not 
surprising that when Sedillot had the courage to bring the 
operation to light again, it was not greeted enthusiastically. 
His results, indeed, were so discouraging that the greatest 
surgeon of his time, Dupuytren, when himself suffering from 
pyothorax, declined to be operated on, uttering the classical 
words that "he would rather die by the hands of God than 
of the doctors." Bearing in mind that the great Velpeau had 
lost all his cases of pyothorax, and that, of fifty cases, Dupuytren 
had only seen four recoveries, his conviction can be well 
appreciated. Most of these cases, however, be it well under- 
stood, were treated by aspiration. Later on Sedillot, seconded 
by Langenbeck, recommended an opening by the trephining 
of a rib. 

It was reserved for the great discovery, antisepsis, to elevate 
thoracotomy to the high pedestal which it at present occupies. 
Especial credit is due to the surgeons Roser, Simon, Volkmann, 
Schede, Kiister, and Konig; but it should not be forgotten 
that the great internists, Kussmaul, Bartels, Lichtheim, and 
Gerhardt, were the pioneers in establishing the proper indica- 
tions for the operation. Full recognition is also due to our 
great countryman, Bowditch, for having first recommended 
exploratory aspiration, a procedure of high practical value. 



Multiple Resection of Ribs. 141 

It now became customary, particularly through the efforts of 
Konig, to combine the resection of a piece of a rib with tho- 
racotomy in suitable cases. Schede, Bardeleben, Runeberg, 
Billroth, Rydygier, Volkmann, Ziemssen, Glaesser, Raczynski, 
Turner, Subbotin, Quenie, and Weir, Bull, and McBurney 
in this country, recommended the method. It was, however, 
understood that resection should be performed especially in 
adults and in cases of long standing, while aspiration and 
simple incision should be preferred in children. The author 
may be permitted to state that in 1882 he advised resection of 
a piece of a rib in all cases of pyothorax without exception, 
as this method offers the best means, not only for sufficient 
drainage, but also for thorough palpation and inspection of 
the cavity. 

As early as 1869 the genius of Gustav Simon found a way 
to heal old pyothoracic cavities by resecting from three to 
seven long pieces of ribs, thus mobilizing the thoracic wall 
and enabling it to adapt itself to the contracted lung. The 
author takes this opportunity to give due credit to this emi- 
nent surgeon, who also performed the first nephrectomy, for 
his ingenious method — an operation which, strange to say, 
is attributed to Estlander of Helsingfors. Simon presented 
cases successfully treated by him by the method described 
above before the Society of Mittelrheinische Aerzte, at 
Mannheim, in 1870, but his untimely death prevented him 
from claiming his priority. An excellent American surgeon, 
Warren Stone, of New Orleans, also performed the so-called 
Estlander operation long before Estlander, and so did both 
Kiister (1873) and Schede. Estlander deserves credit, how- 
ever, for having developed the method further. 

Schede has, as is well known, obtained admirable results 
in old pyothoracic cavities by practically removing the whole 
wall, including the ribs and the pleura. 

Etiology and Bacteriological Examination. — Pyothorax 



142 Intrathoracic Diseases. 

is caused by the invasion of pus-producing bacteria into the 
pleura. Unless from a traumatic cause, it is but seldom of an 
idiopathic character. 

The large pleural surface, being lined with epithelium, is 
not a favorable soil for the development of bacteria under ordi- 
nary circumstances on account of its ability to absorb them and 
carry them off by its numerous lymphatic roads as well as 
by the alternating form of pressure exerted during the process 
of respiration. There is no other organ in the body which 
has such strong means of self-defense, which can only be 
overcome by an extreme virulence of the invading elements or 
a great change of the normal tissue. The latter may be induced 
by pathological processes encroaching upon them from this 
vicinity, by trauma (especially rib-fracture), by anomalies of the 
blood, or by disturbances of the circulation. Among these 
the somewhat antiquated "cold" may be mentioned. 1 

There can no be doubt that immediately after camping on 
cold, moist ground, or after being wet through by rain, the 
symptoms of such diseases as rheumatism and other acute 
complaints may suddenly appear. Such facts happen so 
frequently that they deserve our attention. 

It seems that on such occasions micro-organisms which had 
previously settled in temporary innocence in the organs of 
apparently healthy individuals are set free by vasomotor dis- 
turbances. While proof of such theory cannot, of course, be 
furnished, this much is certain: that even among the most 
hygienic surroundings the surface of the body is covered with 
pathogenic bacteria. Virulent species are found even in 
the mouths of healthy persons. From this well-proved 
fact we must necessarily conclude that it is not bacteria 
alone which produce the disease, but that, besides the 

1 It seems that the rapid variations of climate so characteristic of the State of 
New York predispose more to pleuritis and pleuro-pneumonia than the more equable 
climates of other parts of the country. Winter and early spring show the largest 
statistics. 



Precursors of Pyothorax. 143 

bacterium and the favorable soil necessary for its further 
development, certain other conditions are required, the true 
nature of which we are still unable to determine. The com- 
bination of these conditions represents the favorable soil in 
which the bacterium develops. They may act upon the eco- 
nomy of the body by reducing its vital resistance. Predis- 
position, the term so often praised and so often ridiculed, is 
also an important factor here, just as in tuberculosis and 
other infectious diseases. 

Pyothorax generally develops from a preceding disease, as 
croupous pneumonia, pleuro-pneumonia, gangrene of the 
lungs, hemorrhagic infarction, tuberculosis, pericarditis, peri- 
tonitis, nephritis, osteomyelitis, oesophageal and tracheal ulcers, 
spondylitis, and appendicitis. The infectious diseases, par- 
ticularly measles, scarlet fever, influenza, sometimes diphtheria 
and smallpox, are also important precursors. During the 
extraordinary " grippe" epidemic in 1889-90 pyothorax was 
extremely frequent. 

Pyothorax may also be caused by the perforation of a 
subphrenic abscess into the pleural sac. Abscesses of 
this type may be of stomachic, intestinal, appendicular, 
hepatic, cholangioitic, and of perinephritic origin. Septic 
infection, the various types of tonsillitic and peritonsillitic 
processes, and retropharyngeal abscess may also be causative 
factors. Several times the author has seen pyothorax follow 
grave forms of gastro-enteritis. According to Koplik, a 
streptococcus-pyothorax may be caused even from a slight 
infected wound. 

In the vast majority of cases the precursor of pleuritic 
effusion is pneumonia. Why in one case pneumonia takes its 
well-known regular course, and in another is followed by a 
serous effusion, which is absorbed, and why in still another 
case it gives rise to pyothorax, is also unexplained. 

It would exceed the limits of this work to amplify these 



144 Intrathoracic Diseases. 

theories further. We may, however, learn from them that the 
causal nexus of the aetiological factors of pleuritis, as well as 
of pyothorax, is not yet sufficiently elucidated. Whether in 
some cases of pyothorax the pleuritic effusion was of a serous 
character first and became purulent later on is not yet proved. 
It seems that even the so-called serous effusions, which later on 
" turned into pyothorax," contained the pus-producing ele- 
ments from the beginning of the process, which can, of course, 
not be recognized macroscopically. 

It was expected that bacteriology would bring more light 
that would be utilized in practice, but the most of its 
achievements thus far are of a problematic character. 
The investigations of eminent workers in this branch 
(A. Frankel, E. Levy, Prudden, Koplik, Netter, Weichsel- 
baum, and Prince Ludwig Ferdinand of Bavaria) have shown 
that the pyogenous bacterium most frequently found in pyo- 
thorax is the streptococcus. This coccus could be especially 
cultivated in cases of pyothorax due to trauma, caries of the 
ribs, pneumonia, and tuberculosis of the lungs, and also after 
pyaemia and septicaemia. 

Many pyothorax cases, particularly the so-called meta- 
pneumonic empyemas, are caused by the pneumococcus. A 
considerable number, especially the benign types, show the 
staphylococcus albus and aureus. The pneumococcus is 
more prevalent in children, while the streptococcus is much 
more frequently found in adults. Sometimes the pneumococci 
and the streptococci are present at the same time, and it often 
happens that even more varieties of bacteria are found together. 

During the influenza epidemic the influenza bacillus has 
been frequently found in the protoplasm of the pyothoracic 
pus-cells by R. Pfeiffer. The typhus bacillus, the bacillus 
call communis, and the micrococcus tetragenus and proteus 
are also found in pyothorax. 

It is to be regretted that the most ingenious bacteriological 



Bacteria in Pyothorax. 145 

investigations treat only the pus, but not the diseased 
tissues. 

In tuberculous effusions, be they of a serous or of a purulent 
character, the tubercle bacillus is rarely found. If there 
is any suspicion in this direction it is advisable to rely upon 
the inoculation experiment, viz., to inject some of the aspi- 
rated fluid into the peritoneal cavities of rabbits, mice, or 
preferably of guinea-pigs. Thus, the tubercle bacillus is often 
demonstrated by the development of tuberculosis in the animal. 
Two to three months will elapse, however, before such infor- 
mation can be obtained. When the animal is killed, tuber- 
culous nodules from the size of a pin to that of a bean are 
found, particularly in the large omentum and in other abdom- 
inal organs. 

As to the significance of various pus-producing bacteria, 
it may be stated that the streptococcus is found in at least half 
of all cases of pyothorax. As this coccus is most commonly 
met with in suppurative processes, and has its constant domicile 
in and on perfectly healthy persons, it is self-evident that it will 
frequently be present in pyothorax. It seems that this micro- 
coccus especially tends to the formation of solid masses. Its 
predilection is, as we have seen, for adults, and particularly 
for infectious diseases. 

Frankel' s pneumococcus is more prevalent in the primary 
pyothorax of children, about 25 per cent, occurring in adults 
and 75 per cent, in children. The cases in which this coccus 
is detected show the most benign character of all, so that 
there is some inclination to attribute this to the coccus; but 
it seems to the author that the vitality of the organs and the 
compliance of the thoracic walls are the main factors ex- 
plaining the more benign character of pyothorax in children. 

In tuberculous pyothorax the tubercle bacillus is, in the 
majority of cases, absent. A negative examination, therefore, 
does not disprove the presence of tuberculosis. There are 



146 Intrathoracic Diseases. 

cases where the tubercle bacillus is found, and in others only 
streptococci, staphylococci, and several mixed forms are 
detected. But inoculation experiments show the presence of 
tuberculosis beyond doubt. In 109 cases of pyothorax Netter 
found the streptococcus 51 times; the pneumococcus, 32 times; 
the bacillus tuberculosis, 12 times, and saprogenous organisms, 
15 times. Among the latter, proteus and sarcinae may be 
mentioned. 

Of 274 cases of pyothorax coming under the author's obser- 
vation within the last fifteen years, 144 were examined bacterio- 
logically. There were found: streptococci, 56 times; pneu- 
mococci, 37 times; staphylococci, 28 times; saprogenous 
micro-organisms, 8; tubercle bacilli, none; in the remain- 
ing 21 cases no micro-organisms were found. It must be 
assumed, however, that these effusions were of bacterial origin 
just the same. In three cases, in which no micro-organisms 
could be cultivated, the injection into the peritoneal cavity 
of a guinea-pig produced tuberculous infection. 

As to the technic of bacteriological examination of thoracic 
effusions, it should be borne in mind that the skin of the patient, 
the hands of the surgeon, and the aspiratory apparatus, par- 
ticularly the needle, must be thoroughly aseptic. Rigorous 
scrubbing of the skin with soap and hot water, rubbing with 
alcohol, and afterward washing with bichloride must always 
precede the aspiration, which (see page 131) must be regarded 
as a surgical operation. 

As an additional precaution, the skin must be dislodged 
before introducing the needle, so that the stitch-canal in the 
skin and the one in the underlying tissues shall not be in line 
(Fig. 82). The left index-finger is pressed into the in- 
tercostal space to steady the skin, then the needle is pushed 
forward slowly. If a purulent effusion consists mostly of 
a very thick cheesy mass, the aspiration will naturally be nega- 
tive. The same result may be expected when the needle is 



Microscopical Examination in Pyothorax. 147 

thrust into thick adhesions or into a massive fibrous pleural 
sward, or if the lumen of the needle be blocked by a fibrinous 
coagulum. 

Therefore, when pyothorax is suspected, the needle must 
be introduced several times at different portions, and when 
this also fails, a very large needle should be tried, in order to 
ascertain whether some thick pus could not be drawn through 
it. Sometimes it is preferable to push the needle far forward, 
pull out the piston, and then withdraw the instrument slowly. 




Fig. 82. — Pleural Aspiration, Piston Drawn Up. 

After each negative result it is also advisable to push a 
wire through the needle, thus removing any thick pus which may 
remain adherent to the inner surface of the needle. Occa- 
sionally it will be useful, after the operation, to fill the syringe 
with sterile water, and force the water through the needle 
into a Petri dish. In case cheesy masses are present, small 
particles are sometimes drawn into the interior of the needle, 
where they cannot be seen by the unaided eye, but when 
mixed with the sterile water, they can be recognized under 



148 Intrathoracic Diseases. 

the microscope. In case the microscope does not give 
sufficient information, resort can be had to cultures of 
the fluid. Staphylococci are easily recognized on agar- 
cultures; while it is not easy to distinguish between strepto- 
cocci and pneumococci, as the cultures on agar appear very 
much alike. But the difference between these two cocci can 
be elicited after inoculation upon rabbits or white mice. 

From the foregoing it is evident that bacteriological means 
are not sufficiently far developed to be practically utilized by 
the physician in this special field. When the benign char- 
acter of the pyothorax is demonstrated by the presence of the 
pneumococcus, it has been advised to aspirate the pus instead 
of opening the chest-wall. But in the section on criticisms 
we shall see that this recommendation is of academic inter- 
est only. 

Diagnosis. — The diagnosis of pyothorax is easy in the 
great majority of cases, the symptoms being caused by the 
mechanical consequences of the abscess which compresses the 
intrathoracic organs — that is, more or less fever (chills), emacia- 
tion, and respiratory disturbances. They may be summarized 
as follows: 

History of preceding diseases, such as pneumonia, etc. 
(see foregoing remarks), suppurative processes in the neigh- 
borhood, pyaemia, etc. Furthermore, high and continuous 
fever at the beginning, later on intermittent and interrrupted 
by cold chills, great exhaustion, headache, dry tongue. In 
cases of long standing, oedema of the thoracic wall is observed. 
Percussion reveals perfect dullness. It should be borne in 
mind that in pneumonia the feeling of resistance is much 
more pronounced than in pyothorax, and that between the 
dull areas tympanitic sounds are found. Percussion shows 
that the neighboring organs are more or less displaced if there 
is an effusion. Auscultation reveals absence of the respiratory 
sounds, or at least weakened respiration. With the phonendo- 



Pyothorax and Subphrenic Abscess. 149 

scope fine distinctions are somewhat more easily perceived 
than with the common stethoscope. The vocal fremitus is 
also either weakened or absent. In pneumonia the vocal 
fremitus is increased. 

To these rules, however, there are many exceptions. The 
main differential points in regard to pneumonia have just 
been noted. Other sources of error occur in growths of the 
pleura and of the lungs (sarcoma, carcinoma, lymphoma), 
which also at times produce effusion. In such cases the slow 
course and the entire absence of fever are pathognomonic 
(see above). If, in such cases, an aspiratory needle is care- 
fully introduced, hard masses are felt. Microscopic examina- 
tion of the cells, which are generally contained in the aspirated 
blood, furnishes information in nearly all such cases. Abscess 
of the vertebrae, echinococcus of the lungs, and actinomy- 
cosis may also be suspected. 

Pyothorax is also often confounded with subphrenic 
abscess. Here it should be borne in mind that in subphrenic 
abscess there is generally a history of previous abdominal dis- 
turbance and none of cough and expectoration, as in pyo- 
thorax. The heart is little if at all displaced, and there is no 
excessive action of the thorax or of the intercostal spaces. 
In the lungs, vesicular breathing is found below the clavicle, 
and pectoral fremitus is also clearly perceptible. There is 
a well-marked limit to the region of vesicular breathing, below 
which the expiration murmur is replaced by amphoric sounds. 
Deep, inspiration pushes the boundary-line of the region of 
vesicular breathing much farther down, into areas in which 
formerly no respiratory murmur could be perceived. This 
would indicate a well-marked separation between the lungs 
and the abscess cavity, the boundary-line of the lungs pro- 
truding toward the abscess cavity during deep inspiration. 

It is sometimes impossible to distinguish an encysted 
pyothorax from a subphrenic abscess. The pathognomonic 



150 Intrathoracic Diseases. 

signs of such accumulations are absence of cough and rapid 
change of note if the patient is rapidly turned. Still the 
author's observations show that pleuritic effusions, particularly 
pyothorax, sometimes occur without showing these symptoms. 1 
An error in this direction, however, will be of little practical 
importance, inasmuch as the treatment of subphrenic abscess 
is the same in principle as is that of pyothorax. 

It has been hoped that the Rontgen rays would give some 
more elucidation in these points. But effusions, be they serous 
or purulent, cannot be diagnosticated directly by the rays; 
still, by finding a translucent space, as, for instance, between 
diaphragm and liver, the presence of a subphrenic abscess ap- 
pears to be probable. (See section on subphrenic abscess.) 

The pus-cavity may either be of small extent or contain 
a cheesy accumulation, or it may be divided by adhesions into 
several minor cavities (Fig. 79, C), Or the needle may reach a 
pleural band of great thickness; the author has seen them up 
to the diameter of one and a half inches. 

Sometimes one may be surprised by the result of the ex- 
ploratory puncture, which may be negative although all the 
symptoms pointed to the process of pyothorax at first. 

And, on the other hand, it may happen that all the classical 
symptoms as described above may be absent, and still pyothorax 
be detected at last. The author has repeatedly found pus only 
after many aspirations were made; as in a case where the 
cavity was almost filled up with a cheesy mass, the liquid pus 
present amounting only to a trifle. Under such circumstances 
it is natural that the needle, after being introduced into these 
solid masses, cannot draw any pus. The same negative result 
may be obtained where there are large fibrinous masses in serous 
effusions. 

It has furthermore to be considered that there are exceptional 
cases of pyothorax, where the pus-cells have settled down to the 

1 See: "Pyothorax and its Treatment," "Medical Record," May 13, 1894. 



Mode of Operation in Pyothorax. 151 

bottom of the abscess cavity like a sediment, while above a 
collection of a clear serous fluid is found which, if aspirated, 
would necessarily leave the surgeon under the impression that 
no pyothorax existed. Such misapprehension may come 
all the easier if the exploratory puncture is made high up. 
This fact teaches that punctures should be made below as 
well. It should, however, not be forgotten that it is just in 
the most dependent part that clots are likely to settle which are 
apt to clog the exploratory needle. If in such a case absorption 
of the fluid should take place, and the sediment-like pus should 
undergo thickening at the same time, the negative result of the 
aspiration would give no correct information as to the true state 
of the pleural sac. 

In regard to the technic of the aspiration, the author refers 
to page 131. 

Operative Treatment. — The treatment of pyothorax can 
only be surgical. Its principles are governed by the same that 
apply to any case of large abscess, — that is, thorough evacuation 
and drainage, which can only be achieved by making a wide 
opening in the chest- wall. This demand is so simple that it 
is hard to understand the still antagonistic attitude of some 
physicians to this fundamental surgical maxim. 

A wide opening can only be attained by combining the in- 
cision with the resection of a piece of a rib, the latter being 
such a simple and easy operation that any physician may 
perform it. 

The technic is as follows: Thorough asepsis is just as 
necessary as in any other operation. Particular attention 
must be given to the skin of the patient and to the hands of 
the surgeon (see above). 

All the paraphernalia needed at the operation must, of 
course, be sterilized: the instruments, ligatures, etc., in boil- 
ing soda solution, and the towels, sponges, etc., in steam. 
If no sterilizer be at hand, the towels, sponges, etc., can also 
be sterilized in a boiling pot. 



152 



Intrathoracic Diseases. 



As a rule, the seventh rib is selected. The median axillary 
line is preferred as the centre of the incision, as thence the 
abscess walls can be reached equally well in front and behind ; 
the muscular strata also being thin there. It also enables 
the patient to be brought to the edge of the table during the 
operation, so that he might assume 
the dorsal decubitus; whereas, if 
the incision were made farther 
back, he would be obliged to lie on 
the healthy side, thus rendering 
evacuation more difficult. If, how- 
ever, the dull area, as sometimes 
occurs in abscesses of small ex- 
tent, is far from the median axil- 
lary line, the resection must take 
place at the point where the aspira- 
tory needle revealed the pus. 

It would, of course, answer sim- 
ple surgical rules to make the open- 
ing at the most dependent part of 
the cavity. But it must be borne 
in mind that by following this 
maxim in this special instance the 
diaphragm and even the peritoneum 
might be incised. This is apt to 
happen in cases of recent origin, 
when the diaphragm rises imme- 
diately after the evacuation of the 
cavity. The author even noticed 

that a few minutes after resection 
1890.; , .. . . 

ot the seventh rib the openmg m 

the thoracic wall became obstructed by the rapidly uprising 

diaphragm. 

The incision, about four inches in length, should be made 




Fig. 83. — Exposure of Rib in 
the Median Axillary Line. — 
{Beck, in "Medical Record" 



Use of the Periosteotome. 



i53 



down to the periosteum of the rib selected. Its direction must, 
of course, be parallel to the margin of the rib alongside its 




Fig. 84. — Incision-line in Resection of Rib (the Knife Dividing the Peri- 
osteum). — (Lejars.) 

centre (Fig. 84). The periosteum, both in front and behind, is 
raised by means of a periosteal elevator. Having freed the 
periosteum, the elevator is pushed beneath the rib, between it 




Fig. 85. — Dividing Rib with Rib-shears, while Annular Part of Periosteo- 
tome Retracts the Soft Tissues. — (Beck, "Annals of Surgery ," /aw., 1904.) 

and its posterior^periosteum, and allowed to rest on both edges 
of the wound. With a blunt hook or the annular part of the 
periosteotome (Fig. 86) the tissues are retracted along the rib 



154 



Intrathoracic Diseases. 



toward the axilla, while with a bone scissors the rib is cut be- 
tween hook and elevatorium. Next, the elevatorium is pushed 
toward the sternum, forcing the rib from the last fragment of 
adhering periosteum. 

A simpler way is to free the periosteum by introducing 
the author's annular periosteotome (Fig. 86) and carrying it 



Fig. 86. — Annular Periosteotome. 



Fig. 87. — Author's Rib-shears. 



around the denuded rib. By pushing it to and fro the last 
periosteal fragments are separated from the rib. At the same 
time it may be utilized as a retractor (Fig. 85.) 

If the author's elevatorium shears are used, nothing is 
required but to tear away the connection between the perios- 



Incision of Pleura. 155 

teum and the rib and divide the rib, the instrument being of 
such a shape as to keep the tissues properly retracted. One 
blade, if taken apart, can be used as an elevatorium, so that the 
whole operation could practically be finished with those two 
instruments alone. 

A piece a little over an inch in length is resected. It is 
under extraordinary circumstances (see above), or in cases of 
old standing, that two or three ribs must be sacrificed. 

During these manipulations it is impossible to strike the 
intercostal artery on account of its anatomical situation (see 




Fig. 88. — Incising the Costal Pleura after Removal oe a Piece of a Rib. — 
(Lejars.) 

anatomical part), while in performing simple incision this ac- 
cident has frequently occurred. 

A few drops of tincture of iodine are then applied to the 
wound surface to form a protection against the escaping 
pus; aseptic tampons may also be pressed against the wound 
for the same purpose. 

The very thin thoracic fascia and the costal pleura are now 
incised, the opening being just wide enough to permit the 
introduction of a grooved director. As soon as pus appears 
in the groove of the director a small Pean forceps is introduced, 
and the opening gently dilated. Evacuation of the pus 
must take place slowly, as rapid evacuation might produce 



156 



Intrathoracic Diseases. 



fatal anaemia of the brain, on account of congestion of the 
lungs. The time for evacuation may be from twenty to thirty 
minutes. A sponge should be pressed against the opening from 
time to time to interrupt the stream of pus, thus avoiding too 
rapid expansion of the lungs. The pulse, the respiration, 
and the color of the face should be watched very thoroughly 
during these manipulations. 

If the condition of the patient 
permit, the finger is now introduced, 
and any solid masses, such as fibri- 
nous lumps or necrosed tissues adher- 
ing to the abscess wall, are wiped with 
the index-finger or with sponges 
fastened to a sponge-holder, or even 
with a blunt spoon, which the author 
advised for that purpose. By now 
introducing the pleural speculum 
(Figs. 89 and 90), the whole cavity 
can be inspected. Further cleaning 
is then an easy matter. The solid 
masses are best brought out by an ir- 
rigation with sterile normal salt solu- 
tion. When malodorous pus is found, 
an antiseptic wash, preferably bi- 
chloride of mercury (1 : 5000), is used 
for this instead. 

If haemorrhage should have 
occurred, or if signs of shock 
are present, such procedures may be deferred for a day or two. 
The costal pleura is now stitched to the skin with four 
silk sutures (on suppurating wounds iodoform silk is always 
preferable), one at each end of the wound and one on each 
side, with strong curved needles, sharpened on both edges 
from tip to eye, for ordinary needles break easily when forced 




Fig 



). — Author's Pleural 
Speculum. 



Pleurostomy. 



i57 



through the thickened pleura. Thus the wound surface is 
entirely covered, and the adjacent tissues are protected against 
infection. At the same time secondary haemorrhage is pre- 
vented and the wound kept wide open. This procedure may 
be termed " pleurostomy. " 




Fig. 90. — Pleural Speculum in Situ. 



If more than one rib is to be resected, the periosteum of 
the rib below is divided and the rib resected in the same man- 
ner as the first one (Fig. 91). The costal pleura underneath 
is also incised, a large aneurysm-needle is afterward intro- 
duced through one of the pleural incisions, and conducted 



i58 



Intrathoracic Diseases. 



underneath the costal pleura to the other. With strong silk 
sutures the tissues, containing fascia, muscles, periosteum, 
costal pleura, and intercostal arteries, are ligated en masse 
close to the cut surface of the rib. Then a vertical incision is 




Fig. 91. — Simultaneous Resection oe Two Neighboring Ribs.- 
national Medical Magazine" January, 1897.) 



-(Beck, " Inter - 



made through the tissues between the two ligatures, thus 
creating a wide opening. If the skin is forcibly retracted, 
the integumental incision can be utilized for the resection of 
the rib above. The whole side is then protected with a large 
piece of moss-board, which, after being slightly dipped in 



Anaesthesia in Pyothorax. 159 

water, adapts itself to the contour of the body like a plaster- 
of -Paris dressing. The dressing should, however, be applied 
while the patient assumes the dorsal decubitus, as sudden 
anaemia of the brain might be caused by the erect position. 

The whole pus cavity is packed with 3 per cent, iodoform 
gauze, a narrow strip, several yards long, being preferable 
for that purpose. The packing is done tightly for the first 
day in order to prevent haemorrhage, later on loosely. 

It is only after the rigorous procedures described that the 
cavity can be regarded as entirely evacuated. No necessity for 
subsequent irrigation arises, as all decomposable elements were 
removed. 

Anaesthesia. — Full anaesthesia should be administered 
only if the pulse is strong. This is an exceptional circum- 
stance in all cases of abscesses that have existed for a long 
time. It is well known to what immense dangers a general 
anaesthetic exposes the thoracic organs when their functions 
are so much impaired by compression. Ether being con- 
traindicated in every respiratory disturbance, only chloro- 
form is recommended, as a rule ; and there is no need to call 
attention to the danger to which the use of this paralyzing drug 
subjects the heart. Since the operation takes but a few minutes 
for a well-trained surgeon, it would be better to use local anaes- 
thesia (Schleich's infiltration or ethyl-chloride) when an anaes- 
thetic is required. Even cocaine is by no means void of danger. 
If chloroform is employed, only a few drops should be poured 
into the mask at a time, and the pulse, the respiration, and the 
color of the face should be very carefully watched. A hypo- 
dermatic syringe for the use of stimulants (strophanthus, cam- 
phorated oil), tongue-forceps, and mouth-opener (if available, 
an oxygen apparatus also) must be close at hand. 

After-treatment.— Packing with iodoform gauze renders 
after-treatment simple, since it offers the great advantage that 
no subsequent irrigations are required. This is an important 



160 Intrathoracic Diseases. 

factor considering the unavoidable irritation caused by them, 
which has sometimes led to sudden death, but also because it pre- 
vents the formation of those very adhesions which are so much 
needed for the gradual obliteration of the cavity by the agglut- 
ination of the pleurae. 

No frequent change of the position of the patient is needed, 
as is required when drainage-tubes are used. All the pus is 
absorbed by the iodoform gauze in the cavity as soon as it 
forms, stagnation thus being prevented best, while a rubber 
drain carries off only part of the secretion. Consequently 
there can be no decomposition, and, naturally, no fever. 

The first dressing must be renewed after twenty-four hours, 
the discharge during the first few days generally being ab- 
undant. Except in the presence of malodorous pus it does 
not need to be changed then more frequently than every second 
or third day. The patient, if at all able, should get up after one 
week. During the first few days of the after-treatment small 
doses of morphine are administered for the purpose of immo- 
bilization, especially when cough is present. If the pulse be 
weak, strophanthus and caffeine may be added. Nourish- 
ment is given frequently and in small quantities to avoid 
distention of the stomach. 

If the pyothorax be of short standing the cavity may 
become obliterated in two or three weeks. In one of the author's 
cases, that of a child six months of age, obliteration was perfect 
six days after the resection, but this, of course, must be con- 
sidered an exceptional occurrence. In older cases it may take 
months. The average time for cases of short standing is four 
weeks. Thoracic fistula remained in none of the author's early 
cases. The gauze-moss-board dressing (see page 66) acts like 
an aspiratory valve, which yields to the internal expiratory 
pressure, the latter often being intensified by cough, etc., 
while, at the same time, it resists the inspiratory external 
pressure. In cases of short duration percussion is generally 



Prognosis of Pyothorax. 161 

found normal, and auscultation reveals vesicular breathing 
above the formerly dull area, as early as twenty-four hours 
after operation, the lungs having expanded then. 

This shows that the atmospheric pressure, which is erro- 
neously regarded as hindering the early inflation of the lungs, 
can be of but little importance in this connection. 

The healing process does not take place by granulation, 
but by the distention of the lungs. Where the pulmonic pleura 
approaches the costal, where, in other words, the lungs touch the 
thoracic walls, a portion of the distending lung tissue adapts 
itself to the costal pleura, where it gradually becomes agglu- 
tinated by fibrinous adhesions. 

Prognosis. — If septic and tuberculous cases are ex- 
cluded the prognosis of pyothorax rests entirely upon 
early diagnosis. In other words, it is the family physician who 
is responsible for the final outcome. Among the author's 
cases of this type there is not one, in fact, which ended fatally. 
The operation itself is entirely void of danger if done under the 
precautions described above. The results can only be attrib- 
uted to the thorough evacuation made, and particularly to 
the removal of the solid masses found in the great majority of 
cases. In 62 per cent, of his own cases, especially in children, 
the author found them present to a greater or lesser extent. No 
method except resection enables the surgeon to introduce his 
finger, which procedure renders examination of the cavity 
possible and permits of thorough evacuation at the same time. 

So far there is no method which shows with any possible 
degree of probability before operation whether such fibrinous 
or cheesy masses are present or not. All we know is that the 
streptococcus favors the formation of solid masses. A large 
opening, which can be guaranteed by the performance of a 
resection only, allows inspection and palpation of the cavity 
and represents the means to diagnosticate the presence of 
the solid masses. So long as no information about this most 



162 Intrathoracic Diseases. 

important point can be obtained by any other method, 
resection should always be preferred. 

If performed late in an emaciated patient whose strength 
has failed under expectant treatment, resection will seldom 
avert the fatal result, the lungs having lost their contractility 
after that long period of compression, while the functions of 
the neighboring organs are impaired by the continuation of 
their displacement. 

There are, in fact, no contraindications for the radical 
operation. In the inexcusable cases of long standing, where 
the cyanotic and emaciated patient shows a small and frequent 
pulse, a preliminary aspiration may be done to relieve the 
patient temporarily, resection to be performed on the following 
day then. 

As stated above, the author always insisted upon the resec- 
tion of a piece of a rib in all cases of pyothorax, irrespective of the 
peculiarity of the case, because he has seen cures even in cases 
to the operation of which he had proceeded without a gleam of 
hope, this showing how easily errors of prognosis occur. Even 
in such desperate cases where the tarrying policy had caused 
amyloid degeneration of the liver, ascites, etc., entire restor- 
ation to health has sometimes followed resection treatment. 
Amyloid degeneration on this basis must not always be re- 
garded as a hopeless condition, especially not in children. 

In tuberculous cases repeated cures have been effected, 
and the author's early statements about the advisability of the 
resection treatment in such cases were corroborated by Schede 
and Guterbock, and later by Kiister, Rydygier, Hofmokl, Th. 
Weber, and Koranyi, who reported a number of cures. Re- 
garding the absolute hopelessness of this type of the disease if 
let alone or treated medically, even a smaller percentage of 
cures would indicate the resection treatment. It would also 
be of incalculable benefit if such patients were operated upon 
much earlier. The chances being then much more favorable, 
the number of cures would be considerably augmented. 



Tuberculous Pyothorax. 163 

While primary miliary tuberculosis as well as pyothorax, 
caused by the perforation of a tuberculous cavity into the 
pleura, gives a very poor prognosis, those cases in which the 
pleura has been infected from tuberculous lungs show a consid- 
erable percentage of cures. Mixed infection is generally 
present in cases of this variety, the pneumococcus, staphylo- 
coccus, and streptococcus being also found. 

As mentioned in the section on aetiology and bacteriological 
examination, the tubercle bacillus was not found in the pyo- 
thoracic effusion of a number of these cases, in which, never- 
theless, the presence of tuberculosis could be proved by other 
than bacteriological means of investigation. In other words, 
the absence of the tubercle bacillus does not at all prove the 
absence of tuberculous disease. As long as our diagnostic 
means in this direction are not more reliable, the surgeon will 
always be correct by operating upon every pus-accumulation 
in the pleural sac, whether it is tuberculous or not. 

That exposure to atmosphere and light are also healing 
factors in this connection, as they prove to be in peritoneal 
tuberculosis, appears to be probable. 

Those of the author's cases in which malodorous pus was 
found at the time of the operation invariably died. In all of 
them other grave processes were present, — either tuberculosis 
or multiple pyaemic foci. Some of them were observed after 
grave gastro-enteritis in children. In others tuberculosis 
pulmonum was present, and perforation of a cavity into the 
pleural sac could be suspected. This would mean a futile 
attempt of the vis medicatrix naturce. 

If infectious diseases are the precursors the prognosis is 
much more favorable, especially so after measles and influenza. 
The same view applies to trauma. The prognosis after the per- 
foration of a subphrenic abscess is somewhat less favorable. 

As stated in the section on aetiology and bacteriological 
examination, the cases of pyothorax in which the pneumo- 



1 64 Intrathoracic Diseases. 

coccus is found show the most benign character of all. 
They are prevalent in children. Whether this is due to the 
particular character of the coccus itself is doubtful. It seems, 
as mentioned before, that the vitality of the organs and the 
pliancy of the thoracic walls in childhood are the main factors 
in this more benign tendency. 

Accidents. — There are many reports on accidents which 
have occurred during anaesthesia. By obeying the principles 
emphasized in the section on operative treatment, accidents 
from anaesthesia hardly occur during the operation itself. 
The responsible post of an anaesthetizer should never be left 
to the beginner, whose ignorance of the danger makes him so 
self-confident, his ambition being that the patient should be 
under the influence of the anaesthetic as long as possible. 
Thus he does not resist the temptation to give the drug too 
freely. But, while it is certainly most agreeable for the surgeon 
not to be disturbed by the insufficient anaesthesia of the patient, 
it is nothing less than a crime to subject the patient to any 
greater risk of life than is absolutely necessary. The author 
knows of several cases in New York where the patient died 
under the anaesthesia before the surgeon in charge had an 
opportunity to perform his operation for pyothorax. What 
the legal aspect of such accidents is every surgeon knows. 

Still it is surprising that they do not occur more frequently 
in patients who suffer from large effusions which compress 
one lung totally and the other at least partially, and where 
the heart is displaced and the circulation in the large blood- 
vessels impaired besides. The fact should not be lost sight 
of, that it is less cruel to trouble the patient and to save his 
life than to give him the so-called benefit of a full anaesthe- 
sia and to risk his life under the pretext of humanity. A 
limited anaesthesia frequently leaves an impression only and 
not a clear perception of all the surgical procedures; and 
frequently it is the nervous dread of these procedures, and 



Disadvantage of Drainage-tubes. 165 

not the physical pain itself, which terrifies the most courageous 
patient. The odor alone of an anaesthetic will sometimes give 
the patient the agreeable impression of being insensible to pain. 

Nor is irrigation by any means void of danger, even if 
simple sterile water be employed. It is, therefore, a decided 
advantage of the resection-treatment that it does not require 
this dangerous and annoying manipulation. Alarming con- 
ditions are especially provoked if the irrigating fluid be driven 
into a bronchus, when a communication exists. Violent 
cough paroxysms of long duration are generally observed under 
such circumstances, the patient sometimes succumbing during 
such a paroxysm. 

Sudden collapse has repeatedly followed a too rapid and 
too forcible infusion, or a too rapid evacuation of the pyo- 
thoracic contents. This is safely avoided by slow evacuation, 
as mentioned above. 

Rubber drainage-tubes have often been a source of trouble. 
The mode of after-treatment advised dispenses altogether with 
this crux medicorum. 

The author was called eleven times to extract drain- 
age-tubes which were imperfectly secured (as by one safety- 
pin only), or where the rubber was of an inferior quality, 
so that breakage occurred. Twice he removed drainage- 
tubes, one being nine and the other eleven inches long, 
more than one year after operations performed by Buelau's 
method. Among some physicians a strong predilection exists 
for very long drainage-tubes on the assumption that the longer 
they are, the better they drain the cavity. This is an error. 
Long tubes are nothing less than an obstacle to the expansion 
of the lungs, and do not drain off any more than short ones 
which reach only the internal opening of the cavity. 

As said above, a strong needle should be used in stitching 
the costal pleura to the skin, preferably a Hagedorn needle. 
It has occurred that in uniting the pleura with the skin thin 



1 66 Intrathoracic Diseases. 

needles broke and dropped into the pleural cavity, wherefrom 
they could be extracted only with great difficulty and danger. 
In exceptional cases a large rubber tube may be used in con- 
nection with the gauze-treatment. Then the tube must be 
secured by two large safety-pins, which are attached to the 
wall of the tube in the shape of a cross. 

Criticisms of the Different Methods. — The methods 
used in the treatment of pyothorax are simple aspiration, 
permanent aspiration (Buelau's method), incision, and resection. 

A discussion of the value of the so-called " expectant treat- 
ment" will hardly be expected in a surgical book. Still 
there is no doubt that the vis medicatrix natures is sometimes 
triumphant where either diagnostic ignorance or obstinate 
aversion to surgical procedures dictates therapeutic nihilism. 
There are cases of pyothorax which heal by perforation into 
a bronchus or by absorption, the latter process especially having 
been observed in pneumococcus pyothorax. As such occur- 
rences are extremely rare in comparison with the enor- 
mously large number of the victims of delay, and as we do not 
at all know the conditions under which these marvellous cures 
are effected, such hazardous expectations may well be called 
criminal. It is true that cases sometimes recover not be- 
cause of but in spite of the treatment. But can a rule be 
deduced therefrom? And does not the exception confirm 
the rule rather? Furthermore, if absorption takes place, 
the question arises whether this be really a fortunate event 
for the patient, as clinical experience shows that whenever 
absorption of pus takes place during a considerable length of 
time, a favorable soil for the development of tuberculosis and 
inflammatory processes is created. 

And besides it should not be forgotten that perforation 
into a bronchus might just as well kill directly by causing suf- 
focation. 

Another mode of the vis medicatrix natures deserves men- 



Empyema Necessitatis. 167 

tioning, — namely, the so-called empyema necessitatis, — that is, 
a pus-collection in the pleural cavity which perforates through 
the chest- wall. But of this it may be said that in general it 
would represent nothing but an attempt of nature to heal, and, 
as a rule, not a successful one, inasmuch as the amount of 
drainage it can procure is entirely insufficient. Consequently 
most patients in whom this " fortunate accident" happens 




Fig. 92. — Empyema Necessitatis, following Pleuro-pneumonia, in a Child of 
Three Years Finally Cured by Extensive Resection. 

succumb later to the consequences of pus-retention, unless a 
free opening be finally made. 

R. K. Pel 1 says that the principle ubi pus, ibi evacua has 
justifiable exceptions, and that if empyemata be of small size, 
if the general condition of the patient be excellent, the pulse 
slow and full, fever absent, and the appetite good, absorp- 

1 " Zeitschrift fur klinische Medicin," p. 211, Berlin, 1890. 



1 68 Intrathoracic Diseases. 

tion through thickening can be expected. Such dangerous 
maxims cannot be condemned too much. And as to the true 
dignity of the cases it must be doubted whether the diagnosis 
was correct in the cases of recoveries, no exploratory puncture 
having been tried in any of them. 

If such nihilism is based upon an exclusive consideration of 
pathology, it deserves more attention than if it be simply the 
outcome of ignorance. Nevertheless it does the patient the 
same amount of harm. Medicine is not only a science, but 
first of all it should be a practical art, of which pathology is 
certainly the basis, but still only a part of the entity. Only 
when the two factors, science and art, go hand in hand, does 
the patient obtain that amount of benefit to which he is entitled. 

Regarding aspiration reference is made to the section on 
this subject (page 147). There is a great variety of apparatus 
devised, some of them, like that of Dieulafoy, being very com- 
plicated and expensive. Whether the entering of air into the 
pleural cavity, however, is really such a dangerous occurrence 
as is generally supposed, is not sufficiently proved, still it is cer- 
tainly preferable to always use an aspirator. On the other hand, 
it seems to the author that most of the accidents following sim- 
ple aspiration are rather due to non-observance of aseptic pre- 
cautions, to which careless operators are still inclined. 

As to the therapeutic value of simple aspiration in pyo- 
thorax, the author is satisfied that perfect cures have been 
effected by this method, especially in children, in whom the 
benign pneumococcus is so frequent. (See page 145.) Such 
cures are repeatedly reported. But these few cures amount to 
nothing in comparison to the immense number of those who 
have died under the aspiration-treatment. The author simply 
refers to Dupuytren's experience in aspiration (see page 140). 
Of the author's uncomplicated cases which submitted to early 
resection, not one was lost, but in a large number of his 
patients, who were repeatedly aspirated, and in whom resection 



Fibrinous Clots in Pyothorax. 169 

was practised as a last resort, the radical procedure came too 
late. 

As before stated, in 62 per cent, of the author's cases solid 
masses were found in the pus-cavity. These could certainly 
not be aspirated. Now, if any of our diagnostic means could 
enable us to know whether such masses were or were not pres- 
ent, it might appear pardonable to recommend free opening 
only when solid masses are present, and to try aspiration when 
they were absent. But as long as we possess neither physical, 
mechanical, nor speculative means to make this differentiation 
otherwise than just by making a free opening, that method 
must be chosen which guarantees removal of the solid masses; 
and suppose a case which would have recovered by simple 
aspiration should undergo the more radical procedure of free 
opening, it will certainly not succumb, but will get well just 
the same. 

This kindergarten-surgery is analogous to the well-known 
modus operandi of emancipated mid wives, which culminates 
in the idea that aspiration is evidently a very easy pro- 
cedure; that it is, in fact, "no operation," and the most 
unskilful surgeon can do it. Therefore it finds its most 
enthusiastic advocates among the large contingent of the 
amateurs who are so self-confident that they "never require 
the advice of a surgeon." They are generally the same who 
see all their cases of appendicitis recover without being "fooled 
by the surgeon." When they aspirate, they draw as much pus 
as they can; the patient is then greatly relieved, and so enthu- 
siastic in praising this most agreeable way of being operated 
upon that it would be simply impossible for the surgeon to 
persuade him to such a "mutilating operation" as free opening. 
If the pus accumulates again, the patient gladly submits to a 
second and also to a third or fourth aspiration, because "a stab 
with a needle is hardly felt." But the solid masses in the 
pleural cavity cannot be driven through the calibre of the 



170 Intrathoracic Diseases. 

aspirating needle, nor will they be absorbed. So the aspiration 
is repeated until much precious time is wasted, the patient 
becoming emaciated and the lungs contracted. Then, as a 
last resort, a free opening is made, which at this late stage 
seldom averts the fatal outcome, wherefrom the aspiratory 
enthusiast deduces that free opening, particularly the resec- 
tion-treatment, yields a bad prognosis, and that he, at least, 
"never saw a good result from it," of course. No doubt if 
these surgical caricatures could once see the solid masses in 
the pleural cavity they would condemn their own procedures 
at once. But unfortunately they never see an opened thoracic 
cavity, at least not at the early stage of pyothorax, and so they 
naturally conclude that such masses do not exist. 

Aspiration, however, is by no means always an innocent 
manipulation. The irrigation in the pleural cavity may pro- 
duce epileptic spells, vertigo, nausea, fainting, and even fatal 
collapse. At the same time a nervous surgeon may interfere 
with the intercostal artery. According to reports, death has 
repeatedly occurred from this source through extensive haem- 
orrhage. 

In summing up, it may be emphasized that aspiration 
should be reserved exclusively for exploratory purposes, for 
the cure of so-called serous effusions, and for temporary relief 
in exceptional cases, as described above. In the latter event, 
however, when patients are so exhausted that they would not 
stand resection, resort should preferably be taken to aspiration 
combined with drainage (Buelau's method, page 171). 

As to the definition of serous effusion it may be said that 
those effusions should be called serous which, although they 
may contain a small amount of pus-cocci, still show the light 
color and the characteristic consistency; while pus represents 
a yellow, thick, homogeneous fluid. In practice the differen- 
tiation should only be made from the macroscopical point of 



Suction Method. 



171 



In 1879 Baelz advised the combination of aspiration with 
irrigation. The wish was father of the thought, and it was 
certainly a splendid idea to try to wash out the pleural cavity. 
But the solid particles there are unfortunately of too large size 
to be forced through the canula of a trocar, so that this method, 
which was received with great enthusiasm at first, dropped into 
deserved disuse. 

Permanent Drainage. — The so-called Buelau's or suc- 
tion method (Fig. 93) deserves attention. It is far superior 




Fig. 93. — Buelau's Suction Method. 

to simple aspiration in that it aims to prevent refilling of the 
pus after aspiration. The technic of this method consists in 
introducing through the intercostal space a large trocar, from 
which the stylet is withdrawn, the canula remaining. After 
a rubber drainage-tube is pushed through the canula into the 
pleural sac the canula is removed. The tube itself, which 
remains in situ, is then fastened to the skin with adhesive 
plaster and connected with a long rubber tube by a glass canula. 
The tube ends in a glass vessel rilled with bichloride of mercury, 



172 Intrathoracic Diseases. 

where it is kept by attaching a piece of lead to its end. The 
glass vessel may be represented by a bottle, which the patient 
can carry around in his waistcoat pocket. The advocates of 
this method claim that a permanent evacuation proportional 
to the expansion of the lungs is thus achieved. 

Brilliant, however, as this method appears on a superficial 
contemplation, it has many and great disadvantages. First 
of all, the same objection as against simple aspiration must 
be raised, — namely, that the solid masses cannot be removed 
by suction any better than by simple aspiration. Even the 
enthusiasts of this method admit that the drain is oftentimes 
obstructed by fibrinous coagula. Fever is nearly always 
present, on account of retention of pus. It is but a small 
consolation that, by the introduction of instruments and fre- 
quent irrigations, this perpetual obstruction can be removed, 
and that in the course of time the solid masses become liquefied. 

Another deplorable feature of this method is that the 
drainage-tube comes loose in the wound canal, which will 
finally suppurate, then, of course, the seclusion from the air 
no longer being hermetic. Even as strong an advocate of this 
method as Aust 1 complains that pus which was free of odor 
at the time of the operation repeatedly became septic in the 
later course of the treatment. When the adhesive plaster 
becomes loose the drainage-tube is apt to drop into the cavity, 
and the only way to remove it thence is by free opening. The 
author has seen six cases in which such accidents happened 
after Buelau's method was used; but, as they necessitated 
resection, it seems, after all, that the accident was a fortunate 
event for the patient. 

It is furthermore to be remembered that all such patients 
require much more careful watching than those under radical 
treatment. In fact, the control must be so close that the 
method can be well carried out in a hospital only, wherefore 
it is not apt to become popular in private practice. 

1 "Miinchener medicinische Wochenschrift," 1892, No. 45. 



Simple Incision in Pyothorax. 173 

In cases where the intercostal space is narrower than usual, 
a small drainage-tube can sometimes be introduced only with 
difficulty and after much annoyance to the patient; therefore 
Buelau's method should be reserved for very emaciated patients, 
and then as a temporary resort only. It is a characteristic 
sign that the advocates of this method are all internists. 

Simple incision through the intercostal space has still many 
advocates who claim that a small incision which permits of the 
introduction of a thin drainage-tube fully answers the pur- 
pose of evacuation and drainage. It is also emphasized 
that any general practitioner could make the incision; while 
resection is regarded as a difficult operation, which would 
require the well-trained hands of a surgical specialist. Re- 
section should be reserved, therefore, as a last resort in cases 
where, after several months of unsuccessful treatment after the 
incision method, the ribs had approached each other to such 
a degree as to render drainage imaginary. 

As regards the advice to make a small opening into an 
abscess, it must be considered that, according to commonly 
accepted surgical principles, it is not expected that a small 
opening in an abscess would secure thorough drainage and 
evacuation. Modern surgery dictates that the opening should 
be made as broad as possible. The intention is to expose the 
abscess cavity so much, indeed, that it can be inspected in 
its whole extent, that its walls are palpable, and that its lining 
membrane as well as any necrotic tissue, the latter often 
being present in abscess cavities, can be removed. It is only 
after such rigorous procedures that evacuation could be 
considered to be thorough. The wound discharge will be 
scant and is found in the gauze introduced into the cavity. 
Retention will not occur and, as a natural sequence, perfect 
and quick recovery can be looked for. Nobody expects 
nowadays that a surgeon should " lance" an abscess at any 
other part of the body or introduce a small drainage-tube, the 



174 Intrathoracic Diseases. 

use of which would also imply the necessity of daily irrigations. 
But why should a pyo thoracic cavity be treated on different 
principles ? 

After simple incision the field of operation cannot be 
inspected at all. Only if the intercostal space be very wide, 
which is never the case in children and seldom in adults, the 
surgeon's finger can be introduced; and if the opening permits 
of this, the finger is greatly restricted in its exploratory motions, 
and only small solid masses can be removed. Large masses 
will remain. Adherent clots cannot be detached from the 
pleura, nor can the size of very large masses be reduced inside 
of the cavity, a manoeuvre which would permit of their washing 
out by a subsequent irrigation. Consequently these masses 
have to undergo decomposition, and are dissolved or lique- 
fied under constant febrile elevations, retention of pus, of 
course, always being present. Finally they may be washed 
out, piecemeal, so to say, provided the patient holds out so long. 

As regards the alleged difficulty of resection, the author 
is confident that the physician performs many a more difficult 
operation than that of rib-resection. If he desires earnestly 
to learn its technic, operating once on a lower animal will give 
him the routine that enables him to do it properly. Interfer- 
ence with the intercostal artery happens much more frequently 
in simple incision than in resection on account of the situation 
of the artery below the inner surface of the rib. (See Figs. 31 
and 32.) In resection the incision is made only as far as the peri- 
osteum. So far there are no vessels of any importance. Then 
the further procedures can be carried out with blunt instru- 
ments. The tissues in which the artery is embedded are pushed 
aside so that it can be easily seen and avoided (Fig. 94). If 
such an accident occurs after incision, resection has to be made 
at once, but if the operator is very nervous the patient may bleed 
to death before the operation is completed. On the other hand, 
if this accident should happen after the resection of the rib, 



Importance of Intercostal Space. 



i75 



the artery can be caught directly. Fatal hemorrhage from 
the intercostal artery after incision is reported from several 
clinics (Billroth). 

Should the ribs move together after simple incision, fur- 
ther introduction of a drainage-tube, even if it be of smallest 
size, becomes impossible. This condition, which prevails in 



Integument and sub- 
cutaneous cellular 
tissue 



Externe intercostal 
Lungs as they are seen 
through a small fen- 
estra cut into the 
costal pleura 

Third rib 



Third costal cartilage . 



Interne intercostal 



Superficial aponeuro- 




Integument and sub- 
cutaneous cellular 
tissue 



iDterne mammary 
ganglia 



Chondro-sternal ar- 
ticulation 



Pectoralis major, dis- 
sected and reverted 



Superficial aponeu- 
rosis 



Fig. 94. — Two Intercostal Spaces on the Right. — (Testut and Jacob.) 

the majority of cases, in fact represents a type of the almighty 
vis medicatrix natures, the effort of nature to diminish the 
extent of the cavity. But, unfortunately, the intended remedy 
in this case is nothing but a prevention of the cure, because 
it obstructs the opening. 

As mentioned before, the author has with a few excep- 
tions dispensed with the drainage-tube. Formerlv he used 



176 Intrathoracic Diseases. 

to introduce a rubber drainage-tube of the size of a 
man's index-finger three days after resection. The tube was 
secured by two large safety-pins adjusted through the wall of 
the tube in the shape of a cross. The reason why he did not 
introduce the rubber drain immediately after operation was 
that he had not only witnessed considerable haemorrhage after 
it sometimes, but also observed irritation by friction, this being 
caused by the constant respiratory movements of the pleurae. 
It seemed that as soon as granulations appeared, the pleurae 
also becoming accustomed to the contact with the atmosphere, 
the irritation was well borne. Two weeks after operation, on an 
average, a smaller drain was introduced and gradually shortened. 
When the discharges became scant, the drainage-tube was left 
out and a small strip of iodoform gauze substituted. For the fol- 
lowing few days the patient was watched carefully. Frequently 
the cavity was entirely obliterated on the following day, but 
often union was only superficial, retention of pus occurring 
which was generally heralded by an elevation of temperature. 
Then, of course, the drainage-tube had to be reintroduced. 
After a week the same manoeuvre was repeated until, several 
days after the obliteration, no discharge showed, while the 
temperature remained normal. Sometimes the presence of 
pus was revealed after a grooved director was forced through 
the scar tissue. 

The position of the patient had also to be changed every 
few hours, so as to make the pus flow into the dressing, thus 
trying to avoid its stagnation. The danger of stagnation 
induced Kiister to recommend counter-openings on the oppo- 
site side of the original opening. But all these annoying 
manipulations are rendered unnecessary if the cavity is packed 
with gauze. 

The disadvantages of the drainage-tube in general are, 
in the first place, that no antiseptic influence will be exercised 
upon the wound or the cavity itself; antiseptic gauze cover- 



Advantages of Gauze-drainage. 177 

ing the outer ends of the drainage-tubes preventing decom- 
position of the wound products only after they have left the 
tubes and entered the gauze, so that the absorbent qualities 
of the gauze are not at all utilized. But if a cavity is packed 
with gauze every particle of discharge must be absorbed, and, 
however large the cavity, the pus will be in the gauze only 
and the wound surface must be dry. At the same time the 
antiseptic, with which the gauze is impregnated, exerts its 
influence continuously. 

A drainage-tube does not withdraw or absorb pus, for it 
has no power to aspirate the pus, which merely traverses the 
tube, its lumen being the point of least resistance. In other 
words, the flow through the tube occurs only when pus is 
abundant, which is the first step to its retention. 

In conclusion, the author feels justified in claiming that 
the resection method in connection with subsequent gauze 
treatment is, in contradistinction from all the other methods 
described, a clean, easy, safe, and nearly bloodless operation. 
It guarantees a large opening for a sufficient length of time, 
and makes subsequent operations unnecessary. Thoracic 
fistula in particular is impossible if the method be carried out 
in time. The resected piece, if the periosteum has been pre- 
served, is always restored, as may be demonstrated by palpa- 
tion as well as by the Rontgen rays. 

The author's own statistics embrace 529 cases, observed 
during a period of twenty-five years in the city of New York. 
Among them were 131 below three years; 151 were between 
three and five years; 37 were between five and ten years; 36 
were between ten and sixteen years, and 51 above this age. 
Among them, 40 died. Nineteen of them were children below 
five years ; of the others, 5 were between five and sixteen years, 
and 16 above that age. 

Of the non-complicated cases, where inflammatory pro- 
cesses in the lungs or pleurae had been the precursors, 
13 



178 Intrathoracic Diseases. 

261 were diagnosticated at an early stage. All of them recov- 
ered. In 115 cases the operation was done at a late stage, 14 
of them showing the typical vaulting of the thorax. In 11 
a fistula remained. Seven of these cases ended fatally from 
amyloid degeneration. In one of these cases the fatal end 
occurred sixteen months, in another twenty-one months and 
three years after the operation; in all of them Simon's (the so- 
called Estlander's) operation had been tried. In the latter case 
seven ribs were resected. 

As already noted, if only the non-complicated cases, in 
which resection was performed early, were considered, the 
mortality-rate would be practically nil. But as the author 
has made it a rule to perform the radical operation even under 
the most desperate circumstances the mortality-rate is in- 
fluenced accordingly. Nevertheless, among 86 such cases 
54 recovered in spite of their poor chances. 

Among the fatal cases 15 may be enumerated in which 
malodorous pus was present (so-called stinking empyema). 
Eleven of them were infants; in seven of them grave gastro- 
enteritis was the precursor. In one case, a child of eighteen 
months, gastro-enteritis had been present two weeks before 
the signs of pyo thorax developed. The high fever present in 
the beginning had nearly subsided, but there was always a 
rapid pulse and great weakness, conditions which usually 
point to the constant absorption of toxic elements. In one 
case, where diphtheria was the precursor, pyasmic foci were 
present. No antitoxin had been given in this case. 

In four other fatal cases (one was a mixed infection) the 
presence of tuberculosis was proved by bacteriological exami- 
nation. In three cases of well-developed tuberculosis the 
result was also fatal, in all of them the exitus occurring from 
three to eight weeks after resection. 

In three cases of tuberculosis, where the diagnosis was cor- 
roborated by inoculation experiments, perfect recovery took 
place. 



Statistics in Pyothorax. 179 

Statistics may easily mislead. If, as in some clinics, only 
the favorable cases are operated upon, the statistics will of 
course be more favorable. 

Schede reported seven deaths among eighty-six cases. 
In five of the latter grave septicaemia, pyaemia, and progressing 
gangrene of the lungs had been present. Of the other two, 
one was due to sudden collapse after operation, and this acci- 
dent could, according to Schede's own statement, have been 
avoided under different circumstances, mainly dependent upon 
the surgeon. In the other case, a child of seven months, 
broncho-pneumonia was present on the opposite side when 
resection was performed. This properly reduces the number of 
deaths to two, or perhaps to one only, — in other words, to a 
mortality of not more than 2.4 per cent., or a percentage of 
97.6 of perfect and definite cures. 

Glaeser 1 reports twenty-one perfect cures in cases which 
were highly complicated. In all of them he had first tried 
Buelau's method unsuccessfully, performing resection only 
after the suction drainage had been kept up for seven weeks. 

Konig, among seventy-six cases, lost ten after resection, 
the latter all being complications of the gravest character. 2 

Among forty-four cases of pyothorax J. Raczynski saw 
all those of metapneumonic origin recover after resection. 

Among eleven cases of tuberculous pyothorax resected by 
Kronlein, four recovered perfectly, four died, and three were 
improved. 

Perfect recovery took place in eight of the author's cases 
of amyloid degeneration. These were old cases. 

Some of the advocates of Buelau's method admit, however, 
the occurrence of many failures. Pel, 3 for instance, and 
Quincke report many failures besides their successful cases. 

^'Resectio costarum contra Heberdrainage bei Behandlung der Pleuraempyeme," 
Hamburg, 1890. 

2 F. Konig: "Die Erfolgeder Behandlung eitriger Ergiisse der Brusthohle," " Ber- 
liner klinische Wochenschrift," 1891, No. 10. 

3 P. K. Pel: "Bemerkungen liber die Behandlung der Pleuraempyeme," "Zeit- 
schrift fur klinische Medicin," 17, Bd. 199. 



180 Intrathoracic Diseases. 

Even Leyden, 1 the celebrated clinician of ultraconservative 
tendencies, reports four cases, of which only one was cured by 
Buelau's method, while another one recovered after resection 
which was performed later. The third case died from tuber- 
culosis without being resected ; and the fourth succumbed, after 
having been resected at a very late stage, to exhaustion. 

Thoracic Resection in Old Cases of Pyothorax. — At the 
Ninth German Congress of Internal Medicine, Ziemssen and 
Ewald, the internists, said: "Old cases of pyothorax should not 
exist; and when they did, the attending physician should be 
held responsible for their existence." This may be a rather 
severe verdict; still, in a way, it expresses the truth. 

The histories of old pyothorax observed by the author inva- 
riably reveal the fact that thorough evacuation of the pleural 
effusion was omitted at an early stage, that is, until after the 
expansion power of the lungs was materially impaired or totally 
lost. 

In the great majority of these cases aspiration therapy 
was continued for weeks before radical steps were taken. In 
some of them a simple incision had been made, in a smaller num- 
ber procrastination went so far as to look for healing by the 
development of a so-called empyema necessitatis, and in a 
few cases surgical therapy was not considered at all because 
the pyothorax was supposed to be of a tuberculous nature. 

It may safely be assumed that in all these patients, except 
those affected with tuberculosis, recovery could have been 
expected after timely and thorough evacuation, i. e., by pri- 
mary rib-resection. And yet even in tuberculous pyothorax 
recovery took place in a number of cases after they were treated 
by extensive thorax resection. Similar principles apply to the 
treatment of pyothorax in which other pathological conditions 
prevailed, like emphysema. Complications of this kind naturally 

1 Leyden: "Ueber einen Fall von retroperitonealem Abscess nebst Bemerkungen 
zur Therapie der Pleuraempyeme," "Berliner klinische Wochenschrift," 1889, No. 29. 



Prognosis in Tuberculous Pyothorax. 181 

delay the healing process, even after early resection. When- 
ever the diagnosis of such extraordinary condition was made 
early, the writer performed resection of the thorax wall with- 
out delay. 

As a rule, the expansion power of the lungs can be esti- 
mated at the time of the primary rib-resection. If the case is 
of long duration, the history points to the presence of com- 
plications, and the diaphragm fails to rise, the pulmonal 
pleura approaching the thoracic wall to a limited extent only. 
Then the resection of a small piece of rib is insufficient, as 
practised under ordinary conditions. And if the costal pleura 
appears to be fibrous, thoracic resection should also be substituted 
for simple costal resection . Whenever the condition of the patient 
should not permit of so extensive a procedure, the typical 
primary rib-resection should be performed at the time with a 
view to undertake thoracic resection a week later, when the 
patient has become more resistant. 

As mentioned above, cures in tuberculous cases were 
reported by Schede, Gueterbock, Kuster, Rydygier, Hofmokl, 
Th. Weber, Koranyi, and the author, after free rib-resection. 
In view of the absolute hopelessness of tuberculous pyothorax, 
if let alone or treated medically, even a smaller percentage 
of cures, as reported, would imperatively indicate the resection 
treatment. Patients of this kind should also be operated upon 
much earlier, the chances being much more favorable then. 

While primary miliary tuberculosis as well as pyothorax, 
caused by the perforation of a tuberculous cavity into the 
pleurae, gives a very poor prognosis, those cases in which the 
pleura has been inf ected . f rom tuberculous lungs show a con- 
siderable percentage of cures. Mixed infection is generally 
present in cases of this variety, the pneumococcus, staphy- 
lococcus, and streptococcus being generally found besides. 

Although the tubercle bacillus was not found in the pyotho- 
racic effusion of most of these cases, the presence of tuber- 



1 82 Intrathoracic Diseases. 

culosis could be proved by other than bacteriological means 
of investigation. It should, in other words, be appreciated, 
therefore, that the absence of the tubercle bacillus does not 
prove the absence of tuberculous disease. Thus the surgeon, 
as long as our diagnostic means in this direction are not abso- 
lutely reliable, will always be correct by operating upon any 
kind of pus accumulation in the pleural sac, be it tubercu- 
lous or not. 

In bilateral tuberculous pyothorax, of course, radical steps 
promise little. 

The persistence of a pyothoracic cavity, whether it be 
simple, complicated, or tuberculous, must necessarily lead to 
a fatal end. It is true that the better the patient is situated, 
the longer the inevitable outcome may be postponed, but 
in the end he will succumb just the same. It is difficult to 
understand, therefore, why expectant treatment is still pre- 
ferred to timely resection. 

As described above, the inevitable consequences are that the 
pulmonal tissues as well as the thoracic parietes lose their 
elasticity. By the long continuance of the inflammatory irri- 
tation, the pleuras will be thickened and infiltrated, so that the 
costal pleura finally becomes so hard that it appears like an 
osseous coat-of-mail. At the same time the persistent and 
abundant suppuration leads to amyloid degeneration (Fig. 95). 

In those exceptional cases where the lungs have not com- 
pletely lost their elasticity, efforts were made with the appa- 
ratus of Perthes, which permits of continuous aspiration (like 
Buelau's). But, as a rule, the pulmonal pleura had become 
immovable then, the lungs are fixed and inexpansible ; while at 
the same time the chest-wall fails to show any tendency to sink 
in. To enforce collapse of the chest-wall has been the aim of 
the various operative procedures advised ever since Gustav 
Simon made the first suggestion of multiple rib-resection. 

Ingenious, however, as Simon's method is, its practical ad- 
vantages are small, because their indications are limited for 



Expansion of Lungs. 



183 



the reason that the pleurae are left untouched. Even Kiister 
and Estlander, who deserve credit for extending the operation, 




Fig. 95. — Resections in Old Pyothorax. — {Testut and Jacob.) 

A. Old pyothoracic cavity before radical operation, the compressed lung being lined 
by a fibrous membrane. B. The cavity filled up after the collapse of the thoracic 
wall is attained by multiple resection, the pulmonal pleura being attached to the 
thorax. C. Ideal expansion of the lung, as it is intended by Delorme after decor- 
tication. 




Fig. 96. — Flap-formation in Total Resection of Chest- wall. 

failed to recognize the main obstacle for the healing process 
in the thickening of the pleura. They maintained that the 



184 Intrathoracic Diseases. 

pleura should be a noli me tangere, and that the pleural wheals 
were useful and necessary for the formation of adhesions be- 
tween the pleurae. It was the genius of Schede which recog- 
nized this fact, on which the principle of resection of the thorax 
is based; in other words, that since the pleurae represent a 
coat-of-mail as firm as osseous tissue, they must share the fate 
of the ribs, i. e., removal. Simon's original idea thus formed 




Fig. 97. — Flap Replaced and Gauze Drain Led through Fenestra in it. 

the stepping-stone to the more perfected method of Schede 
(Figs. 96, 97, and 98). 

Schede' s principle is carried out in practice by the exposure 
of the cavity through an incision reaching from the fourth rib, 
running in a curve downward to the posterior axillary line on a 
level with the tenth rib, and then up again in a curved direc- 
tion on the medial side of the scapula. In this way access is 
expected to be gained to the largest cavities (Fig. 98). 



Principle of Schede Operation. 185 

While the principle of Schede, as far as the removal of 
the pleural tissue is concerned, must be held as irreproachable, 
there are some objections to the details of his technic. First of 




Fig. 98. — Outlines of Horseshoe Flap in Schede's Operation, which was 
Performed Two Years after Permanent Drainage was Tried. (Cured.) 



all, the fact must be considered that most of the cases of old pyo- 
thorax do not need so severe a procedure; in other words, that 
Schede's method reaches beyond the mark. It is, in fact, in 
its general execution one of the severest of operations; and it 



186 Intrathoracic Diseases. 

offers no little danger to the patient, who is generally much 
weakened through prolonged suppuration. It is also to be ap- 
preciated that the method is not only performed by the skilful 
hands of its inventor, but also by the average surgeon, and si 
duo jaciunt idem, non est idem. 

As a matter of fact, the tendencies of modern surgery are 
toward the development of atypical operations. Even the 
fundamental principles of incision for amputation, sacred for 
thousands of years, and formerly the piece de resistance of the 
old masters, have become shaky, the surgeon nowadays 
adapting himself to the individuality of the case. And if we 
consider that old pyothoracic cavities show a many-sided 
picture which even the all-penetrating Rontgen rays cannot 
faithfully portray, it becomes evident that a typical method of 
resection is applicable in a minor number of cases only. Of 
course, we can measure the extent of the cavity by pouring 
in fluids, and the Rontgen rays give us an inlook after the 
infusion of iodoform-glycerin, which marks the shadows. 
Skiagraphy also proves uniform opacity in necrosed conditions 
of the pleurae, while fluoroscopy shows how far the mobility of 
the ribs is interfered with. But none of these points, while they 
are of great academic interest, furnishes the detailed factors of 
a plan of resection. 

Probing is extremely uncertain, because the cavity is always 
more or less irregular; the fistulous tracts are generally 
twisted and often of a meandering nature. The probe, by being 
arrested by projecting pseudo-membranes, is an altogether un- 
reliable indicator of the topography of the cavity. The con- 
sideration of this deficiency of our examining methods has led 
the author to employ procedures which would fit each indi- 
vidual case ; in other words, which would permit of forming a 
detailed plan of operation while operating. In other words, a 
large exploratory incision should precede the operation, the 
details of which will then be dictated by inspection and palpa- 
tion. 



Principle of Exploratory Resection. 187 

As described above, exploratory incision in diseases of the 
pleura was performed by the author with good results. In 
his first case, for which he is indebted to Dr. I. M. Rottenberg, 
of New York city, fibrous degeneration of the pleura as a con- 




Fig. 99. — Exploratory Incision Line Above Old Fistula, in a Boy of Five 
Years, Treated by Simple Incision Eighteen Months Before Exploratory 
Resection of Chest-wall and of Lower Portion of Scapula. 

Note scar of fistulous opening below incision line. (Cured.) 

sequence of a long-standing inflammatory process had taken 
place. Considerable respiratory disturbances were caused, 
which could not be explained satisfactorily. Exploratory re- 
section of a rib in the region of dullness not only enabled the 
author to recognize this condition, but also gave the chance to 



188 Intrathoracic Diseases. 

remedy it by removing the enormously thickened layers of the 
pulmonal pleura. 

The experience gained in this case induced the author 
to try the principle of gradually and methodically proceeding in 
cases of old pyothorax, and with gratifying results, as described 
in an essay on Pyothorax, in the " International Medical 
Magazine," January, 1897. 

The modus operandi of this exploratory method consists 
in resecting the rib which lies approximately in the middle of 
the roof of the cavity, regardless of the pleural fistula, as illus- 
trated by Fig. 99. The fistula is utilized for the passage 
of a sound, but during the operation itself it is avoided, because 
in old cases osseous projections are formed around the fistulous 
tract which make the direct method difficult (see Figs. 106 and 
108), most of them being more easily reached from the side. The 
pleura underlying the resected rib is now incised. By means of 
a lateral incision enough room is gained to inspect a large part 
of the cavity and to palpate the cavity walls. The use of the 
pleural speculum (Fig. 89) originally advised for primary resec- 
tion is not necessary in such cases. 

If the cavity is small and the patient in a fairly good con- 
dition, which is exceptional, then the next two or three ribs are 
resected in proportion to the extent of the cavity beneath, while 
the soft parts are held back with sharp retractors. The cos- 
tal pleura is then excised by means of a blunt-pointed knife. 
If the fibrous tissue is very hard, then the lumen of the in- 
tercostal arteries is so much diminished by compression that 
the haemorrhage can be regulated by temporary pressure. 
Then soft parts and ribs may be divided at the same time. 
Although this formation of wheals is to be expected especially 
in very advanced cases, one should not rely too much upon such 
helps of nature, but make sure by means of a temporary pro- 
phylactic ligature en masse. This is carried out best by the aid 
of a large aneurysm needle (Fig. 91). In more extensive cases 



Technic of Exploratory Resection. 189 

the ribs are divided successively in the same manner; the pre- 




Fig. 100. — Skiagraph of Case Illustrated by Fig. 99, Six Weeks after Resection 

of Three Ribs and Lower Portion of Scapula. 

Note reformation of osseous tissue from the periosteum. 

sumptive length of each piece being ascertained by palpation 
as it is incised. Palpation also tells whether the pleura below 



190 Intrathoracic Diseases. 

the ribs is still elastic or must also be sacrificed. The incision 
of the soft parts proceeds likewise, which results in the forma- 
tion of an irregular flap. But no particular attention needs 
to be paid to the shaping of the latter, as it must depend more 
or less upon that of the cavity. Accordingly, cross-incisions 
may also be made. If a portion of the scapula is found to be 
in the way it is excised. 

The muscular flap set free by the resection of the scapula 
can be utilized for the purpose of partially filling up the under- 
lying cavity (Figs. 99 and 100). 

A mentionable point, to the author's knowledge not yet 
presented in literature and not of rare occurrence, is the con- 
cave arrangement of the lung surface which overbridges a 
certain amount of the cavity. The lateral parts of the pul- 
monary pleura succeed here in attaching themselves to the 
costal, fibrous adhesions holding them there. But the mid- 
dle portion does not follow, and now it represents the floor 
of the cavity over which the approximated sides form the 
roof. The picture of this remarkable condition can be com- 
pared with that which results when one presses in the lung 
surface with the thumb so far that the sides of that segment 
of the lungs collapse in a funnel-like ring around it. This 
resembles the longitudinal fold formed of the gastric wall when 
united in Witzel's method of gastrostomy over a tube, so that 
a canal is made of it. (Compare Fig. 79, C.) 

Special caution is necessary at the beginning of the opera- 
tion in this instance. Suppose in a case of this kind the incision 
were to be made directly, without first exploring the cavity 
thoroughly, then the lungs would be injured. By locating the 
area of the thin portion, that is, where the pulmonary pleurae join, 
access is easily gained to the cavity by first carefully dividing 
the fibrous tissues. Blunt dissection is preferable during this 
procedure. The lateral portions then gape apart and the 
circular cavity is transformed into a flat one. Partial decorti- 



Resection of Scapula. 191 

cation is also advisable then. It appears that the right 
half of the lung is particularly prone to this sort of adher- 
ence, that is due perhaps to the presence of the middle segment, 
which seems to have a tendency to be drawn toward this direc- 
tion during the healing process. 

The fact that the scapular region is the predominant seat 
of old cavities explains some of the technical difficulties in- 
curred in the attempt to produce an artificial collapse of the 
chest-wall. While in 21 per cent, of the author's cases the 
anterior, and in 8 per cent, the lateral, thoracic region was 
affected, the posterior area figures with 71 per cent. If it is 
considered that the posterior chest-wall excels in firmness 
and rigidity, it will be understood that its collapse is produced 
with more difficulty than in front. Consequently, cavities 
show a much greater tendency to establish themselves there. 
It is evident that the artificial collapse can only be effected 
if all obstacles are removed; in other words, if the portion of 
the scapula which may prevent access to the underlying cavity 
is also eliminated. (See Fig. 99.) 

Similar principles apply to the apex of the pleural cavity, 
which is not at all touched by Schede's procedure. Just as in 
the scapular region, it is only the removal of the respective 
cavity roof which makes its collapse possible. The vicinity 
of the subclavian vessels seems to have prevented surgeons 
from invading this field for that purpose. Still, there is no 
other choice than to remove the costal dome. The risks of 
this operation are greatly lessened by the author's method, which 
is simple and comparatively safe and can be performed to 
a limited as well as to a large extent, just as the individuality 
of the case demands it. 

With the arm at right angles, the incision is led close to 
the lower border of the pectoralis major muscle in a horizon- 
tal direction till it ends at the lower part of the anterior margin 
of the deltoid muscle. The muscles are then dissected back 



192 Intrathoracic Diseases. 

superiorly until the axillary region is free. The -vessels and 
muscles are grasped by strong blunt retractors and pulled upward. 
Sometimes separation is possible only by the aid of lateral 
incisions into both pectorales. Thus the vessels are tempo- 
rarily placed hors de combat, and the ribs can be removed 
according to the principles emphasized. If it should be dim- 
cult to reach the first rib by means of this pectoro-axillary 
incision, then the clavicle must be resected temporarily. 

The decorticated flap is then trimmed and placed on the 
pulmonary surface of the pleura. If pieces of the pulmonary 
pleura have been removed, agglutination is much easier. It is 
difficult to remove callous areas in debilitated patients, their 
weak pulse sometimes preventing the surgeon from finishing 
the operation in one seance. But whenever possible, a second 
procedure should be avoided, for a supplementary operation 
always destroys some of the fruits of the first. Of course, in a 
case of doubt, we rather sacrifice them for the patient's safety. 

This kind of decortication is obtained by flat, saw-cutting 
incisions similar to those employed in preparing microscopic 
sections. The principle is akin to that of the temporary resec- 
tion, followed by decortication of the pulmonal pleura, as advised 
by Fowler and Delorme. But it is practised only as the ne- 
cessity arises during exploratory section, and then as a sup- 
plement to the resection of the costal pleura. 

Ingenious as the idea of methodical decortication is, how- 
ever, clinical experience shows that it is only in a small series of 
cases that the lungs expand fully after the pulmonal pleura 
is mobilized. Therefore nearly always a resection of the chest- 
wall must be added to decortication of the pulmonal pleura. 

Garre 1 tried decortication repeatedly, but always with an 
unsatisfactory result. He also believes that the results of 
the procedures are entirely due to the interference on the 
chest-wall. 

1 XXVII Kongress der Deutschen Gesellschaft fur Chirurgie, 1898. 



Exploratory Pneumotomy. 



i93 



Jordan 1 and Krause 2 report similar results from this com- 
bination. 

The same principle was obviously applicable to the treat- 
ment of lung abscess, and therefore the author recommended the 
exploratory pleurotomy and pneumotomy in cases in which 




Fig. ioi. — Thoracic Fistula Continuing after Schede's Operation. 



other methods, especially aspiration, failed. 3 Later, Turner 
reached the same conclusion. 

During the after-treatment stress is to be laid upon early 

1 "Beitrage zurklin. Chir.," Bd. xxxiv. 

2 Ibid., Bd. xxiv, v. 1. 

3 See, on the diagnosis and treatment of abscess of the lung, "New York 
Medical journal," August 28, 1897. 
14 



194 Intrathoracic Diseases. 

gymnastics which favor expansion of the lungs. To this end 
the author recommends dumb-bells and practice on a bugle. 
If these procedures are not neglected, deformities of [the 
thoracic side or the spinal column are not observed. As an 
example the case illustrated by Figs. 101, 102, and 103 may 
serve. 




Fig. 102.— Collapse of Chest-wall after Pectoro-axillary Resection. 

It represents a man of forty years, who was seized with 
pleuropneumonia four years before the closure of the cavity. 
Aspiration was tried first; later, the purulent effusion was dis- 
charged by the incision method. The thickened pleura de- 
manded repeated rib resections, altogether four thoracotomies 
being undertaken. Schede's operation was finally performed 



Failure of Schede's Method. 195 

two years later (Fig. 10 1). But, although this was done in the 
most skilful manner, the cavity did not become obliterated, 
for the reason that only its lower portion was situated within 
the extent of the horseshoe flap, while the upper part was not 
at all touched. And this area represented a large cavity in 
itself. 




Fig. 103. — Considerable Shrinking of Left Side after Multiple Rib-resection 
(Note Straight Attitude). 

When the author saw the emaciated patient for the first 
time operative exploration in the upper thoracic region 
revealed the presence of a large and irregular cavity 
which extended as far as the first rib anteriorlv and 



196 



Intrathoracic Diseases. 



to the second in the dorsal region. The anterior area was 
exposed first, the fibrous tissue being extensively and atypically 
removed in order to get better access to the cavity, so that the 
wound treatment could be done more effectively. The patient 
improved soon afterward, so that his condition permitted of 




i 



1 



Fig. 104. — Late Resui 



er Anterior Resection of Right Thoracic Wall. 



a more severe interference. The upper four ribs were then 
exsected after access was obtained by the pectoro-axillary 
incision described above. This resulted in considerable col- 
lapse of the anterior chest-wall, which was gradually followed 
by the obliteration of that portion of the cavity (Fig. 102). Six 
months later the removal of the posterior rib portion, together 



Rib-stumps After Resection. 



197 



198 Intrathoracic Diseases. 

with the lower part of the scapula, was undertaken. The 
cavity then gradually filled up. There is, of course, deformity 
in proportion to the enormous collapse of the chest- wall. But 
the patient's attitude is straight, nevertheless (Fig. 103), 
which is to be attributed to his continuous exercise. A skia- 
graph taken then showed the anterior aspect of the cavity after 
the first exploratory operation, and another the rib defect at 
the posterior aspect. The signs of inflammatory atrophy of 




Fig. 106. — Synostosis around a Rubber Drainage-tube, Forming a Bony Canal; 
the Small Osseous Fragments Represent Stalactite-shaped Projections 
as the Result of Osseous Proliferations. 

the bones due to the absorption of calcareous matter are 
recognized as an expression of which the poor contrast between 
bony and soft tissues must be regarded. 

Fig. 104 represents a man of thirty-eight years, who suffered 
from a pyothoracic cavity, treated by simple incision for three 
years until the masterly hand of Billroth exsected part of the 
anterior thoracic wall, which was followed by prompt recovery. 

Although five ribs were sacrificed there is no indication of 



Osseous Projections an Obstacle. 199 

any deformity, the patient having been under the author's ob- 
servation for fifteen years. 

The regenerating tendency of the resected ribs is illustrated 
by the Rontgen rays (Figs. 100, 105, and 108). 

As illustrated in previous essays, 1 the Rontgen rays also 
offer splendid means of studying the various stages of bone 
proliferation after resection. 

The photographs (Figs. 106 and 107) represent the results 
of such processes, Fig. 106 showing synostosis around the 




Fig. 107. — Bony Union between Two Ribs without Channel Formation; after 
Incision Method. 

drainage-tube so that a complete bony canal was formed ; 
and Fig. 107 showing synostosis without channel formation. 
The small bone fragments of Fig. 106 illustrate the stalactite- 
shaped formations obtained from old fragments. The skia- 
graph (Fig. 108) illustrates similar formations two months after 
resection. 

The development of these irregular masses deserves close con- 
sideration. Their shape is apt to injure the pleura, a fact which 
teaches the necessity of methodical exercise at an early period, 

1 See "International Medical Magazine," January, 1897. 



200 Intrathoracic Diseases. 

that is, of forcible inspiration as long as the area in question is 
soft and yielding; in other words, as long as there is no de- 
position of calcareous matter in the regenerating bone tissue. 

Sometimes these irregular bone formations may cause 
disturbances to such an extent that their removal becomes 




From Beck's " Rontgen-Ray Diagnosis, 11 copyright, 1904, by D. Appleton and Company. 

Fig. 108. — Regeneration Process aeter Resection of the Fifth, Sixth, 
Seventh, and Eighth Ribs, and of a Portion of the Scapula. Two 
Months after Resection for Old Pyothorax. 



necessary. Where extensive proliferation is to be anticipated, 
the periosteum should be removed, therefore, together with the 
ribs. 

As to the inflammatory irritation as an inducing factor in this 



Hydrothorax and Hemothorax. 201 

abundant osseous formation, as well as to the inflammatory 
atrophy causing absorption of calcareous matter and conse- 
quently translucency of the ribs by the Rontgen rays, the 
author refers to "The pathologic and therapeutic aspects of 
the effects of the Rontgen rays," "Medical Record," January 
18, 1902. 

Schede's advice as to the outlining of the skin-flap has 
been modified by Helferich, Sudeck, and Tietze. In suitable 
cases these modifications yield good results. But none of 
them can be utilized as a general method, like the exploratory. 



HYDROTHORAX. 

Hydrothorax is always a consequence of a disturbance in 
the circulatory system, especially in nephritis and cardial insuf- 
ficiency. In contrast to the effusion produced by an inflam- 
matory process, this transudate is generally bilateral. The 
fluid is more opaque than that of the common serothorax, con- 
tains less albumin, wherefore its specific gravity is smaller than 
that of an ordinary effusion. In view of its aetiology hydro- 
thorax cannot be the object of radical surgical interference. 
If the disturbance caused by mechanical pressure is great, 
palliative aspiration-treatment is indicated according to the 
principles described in the section on aspiration. 

HEMOTHORAX. 

Haemo thorax is produced by a penetrating trauma injur- 
ing one of the large blood-vessels or by the pathologic corrosion 
of a vessel in the pleural cavity ; or it may take place in a tuber- 
culous cavity, in rib-caries, or in aortic aneurysm. 

The signs of haemothorax are well marked : extreme anaemia 
of the skin-surface, collapse, fainting-attacks, frequent pulse, 
and great weakness being present. The treatment is, as long 



202 Intrathoracic Diseases. 

as the original cause cannot be remedied, only of a palliative 
character; hypodermatic saline infusions (Fig. 81) or intrave- 
nous injections being the most potent means. The coagulation 
of the blood in the chest cavity, however, in exerting pres- 
sure upon the bleeding surface, is sometimes an efficient factor in 
arresting the haemorrhage. The respiration, on the other hand, 
is an irritating moment, wherefore an immobilizing ten- 
dency should prevail, which is best supported by the adminis- 
tration of narcotics, like morphine or codeine. Even a slight 
cough may keep up the haemorrhage, wherefore its prompt 
suppression by narcotics is most important. 

After the patient has survived the haemorrhagic shock he 
is still in great danger on account of the presence of the bloody 
effusion, which is apt to decompose. This necessitates thorough 
observation and readiness to interfere as soon as aspiratory 
puncture proves the presence of pus. Under such circum- 
stances an irregular fever curve will point to suppuration. 



CHYLOTHORAX. 

Chylothorax is produced by an injury of the thoracic duct 
inside of its course in the thoracic cavity. Such injury takes 
place in vertebral fractures, an osseous fragment being pushed 
into the duct, or on account of violent compression of the thorax 
by heavy machinery. Some of the cases are due to malignant 
growths in the thoracic cavity, especially to carcinoma of the 
pleura or the lymph-glands which are situated in the region of 
the junction of the duct with the left subclavian vein. The 
diagnosis is made by proving the presence of chyle by explora- 
tory puncture. Pure chyle has a serum-like appearance and 
its analysis reveals the presence of sugar. 

The prognosis hinges on the question whether the natural 
pressure exerted by the exudate itself is strong enough to stop 
further leakage. Literature reports a small number of cases 



Anatomy of the Lungs. 203 

which have thus recovered. Immediately after the injury 
there is no indication for surgical interference, while later aspira- 
tion of the exudate is in order. 



THE LUNGS. 
Anatomical Part. 

The lungs (pulmones) occupy both sides of the chest as two 
elastic sponge-like organs of a conical shape. They are sepa- 
rated by the heart as well as the other mediastinal contents. 
The concave base of each lung rests on the convexity of the dia- 
phragm, while its tapering apex is situated in the upper thoracic 
aperture. The exterior concave surface adapts itself to the 
lateral thoracic concavity, while the inner depressed surface 
forms a niche for the heart. Besides there are two borders, 
the anterior being sharp and thin. It overlaps the anterior 
surface of the pericardium. The posterior border is round- 
shaped and broad. It is larger than the former and extends 
between the diaphragm and the ribs. Another long and deep 
fissure, which penetrates nearly to the root, divides the lung into 
two lobes. The right lung, however, is also divided by an 
additional fissure, which is considerably shorter than the main 
fissure, by which a small triangular lobe is created (middle 
lobe). 

The root of each lung {radix or pedunculus pulmonis) is 
a pedicle, composed of the undivided portion of the bronchus, 
the pulmonal artery, and the two pulmonal veins, and in addi- 
tion the bronchial vessels, which nourish the pulmonal paren- 
chyma, the bronchus of the anterior and posterior pulmonary 
plexuses, and a few bronchial lymph-glands. The whole is 
held together by connective tissue and covered by the pulmonal 
pleura. 

As mentioned in connection with the anatomy of the pleura, 
the pulmonal pleura forms the coat of the lung, which on account 



204 



Intrathoracic Diseases. 



of being tightly attached to it, makes its detaching difficult. The 
whole smooth and shining surface of the normal lung is divided 
by numerous dark lines into small angular spaces (insulae pulmo- 
nales) which are the expression of the borders of the pyramidal 



Pectoralis major 
muscle 

Pectoralis minor 
muscle 

Superior 
lobe 
^ Serratus 
magnus 
muscle 




Diaphragm 
Sternun 

> Ensiform cartilage 

Fig. 109. — Anterior View oe the Thorax with Chest Wall Removed, Show- 
ing the Lungs. — (Morris, Modified from Bourgery.) 

lobes of the lung tissue (pulmonal lobules), each of which repre- 
sents a separate lung en miniature. It is estimated that the 
lungs contain about 1800 millions of lobules. 

The function of this most important viscus is to change 
the venous blood into arterial during the act of respiration. If 



Respiratory Motions. 205 

filled with blood, the weight of the lungs amounts to about two 
and one-half pounds in the adult — in women somewhat less. If 
they do not contain any blood, the specific weight is less than 
that of water, which explains the transparency of normal lung 
tissue on the Rontgen plate. Inflamed lung tissue, especially 
in a state of hepatization, becomes solid and therefore imperme- 
able by the rays. Lungs, or parts of them, which did breathe, 
swim on an aqueous surface, a phenomenon which differentiates 
dead-born children from those which died after birth. 

During inspiration the lungs become enlarged in proportion 
to the distention of the thorax, which is produced by the action 
of the respiratory muscles. The friction produced by the in- 
haled air at the angles of the bronchial ramifications as well as 
by the distention of the lobules at their terminus, finds its 
marked expression in a noise which is perceived during auscul- 
tation as vesicular breathing. It is an important pathogno- 
monic factor that this noise is absent in all diseases of the chest 
which are characterized by the presence of exudates. 

During expiration the lungs become diminished in size. 
This is automatically caused by the elasticity of the lungs and 
the thoracic wall as soon as the inspiratory muscles cease to 
functionate. 

The average number of inspirations in a normal adult is 
sixteen. The anterior margins of the lungs change their posi- 
tion during the process of inspiration, so that they draw nearer 
to the pericardium. Thus the heart is somewhat more em- 
braced, so to say, the consequence of which is a weakening of 
the heart-sound during that period. The lateral surfaces of the 
lungs glide along the thoracic wall, the apices somewhat pro- 
jecting beyond the margin of the first rib, behind the scalenus 
anticus muscle. The friction caused there may explain the 
predisposition of this sphere for the development of tuberculosis. 



2o6 Intrathoracic Diseases. 



SURGICAL DISEASES OF THE LUNGS. 

Abscess op the Lungs. 

While the propriety of the surgical principle " Ubi pus, ibi 
evacua!" is nowadays recognized in all parts of the human body 
that are accessible to the scalpel, there is a feeling of hesitation 
in regard to pus accumulations in the lungs, although they are 
by no means of rare occurrence. This timidity in attacking 
lung abscesses with the surgical knife is apparently caused by 
the widespread prejudice that they are all of a tuberculous 
character and could consequently not be cured by simple 
evacuation. But while there is no doubt that the presence of 
one tuberculous abscess presupposes the affection of a more or 
less extensive area of lung tissue, which would certainly be but 
little influenced through the opening of a single abscess, still 
there are numerous abscesses of an entirely different character, 
that is, such as are caused by preceding inflammatory proc- 
esses, by suppurative bronchitis, bronchiectasis, etc. These 
being of a non-tuberculous character, they are curable, if treated 
after true surgical principles. If this fact were fully realized, 
the medicamentous armamentarium of euthanasia would be 
given up in many cases of alleged phthisis. 

As to the pathology of lung-abscesses, it is recommend- 
able to divide them into acute or chronic or such as are caused 
by a foreign body. The acute abscesses may be either simple, 
or of a putrid or gangrenous nature, while the chronic abscesses 
and bronchiectases may also be either simple or putrid. 

The diagnosis of lung-abscess is made by the presence of 
copious purulent expectoration, its admixture of elastic fibres 
and blood-pigment, the history of a preceding inflammatory 
process, particularly of pneumonia, which has run no typical 
course, the physical signs of the presence of a cavity, and the 
absence of tuberculous manifestations, etc. 

As to localization, it must be borne in mind that while cavi- 



Abscess of the Lungs. 207 

ties of the apex contain more or less air, those situated farther 
below show purulent secretion only. If in the latter variety ex- 
pectoration is copious, so that the cavity becomes evacuated, 
the respiratory sounds become tympanitic on percussion, and 
are clearly perceptible on auscultation. If, on the contrary, the 
cavity is rilled up, there is complete dullness, and the respira- 
tory sounds are hardly, if at all, audible, pectoral fremitus also 
being absent. Cavities of recent origin are more easily localized 
than old cases, not only because the course of the precursory 
disease furnishes clearer information, but also because the 
physical symptoms are much more pronounced. Old cavities 
are, with few exceptions, deeply situated, and can generally 
be reached below the lower angle of the scapula. 

Exploratory puncture, while quite reliable in pyothorax, 
often fails to disclose lung abscess, and has therefore to be 
replaced by exploratory pleurotomy or pneumotomy. In favor- 
able cases the abscess is located by the Rontgen method (Fig. 
no). As to the technic, see section on Rontgen examination 
of chest, page 249. 

The treatment is governed by the same principles as those 
applying to any case of abscess — that is, thorough evacuation 
and drainage. This can be done only by making a wide open- 
ing in the chest-wall. To accomplish this, the resection of at 
least two ribs is required. 

The technic is as follows: Thorough asepsis is just as 
necessary as in any other operation and is practised after the 
principles emphasized in the section on asepsis, page 62. 

As a rule, the eighth rib is selected first. The skin incision, 
about rive inches in length, should be made in the centre of the 
selected area and carried directly down to the periosteum of 
the rib. The further steps are carried out in accordance 
with the rules laid down in the description of the performance 
of rib-resection (see section on pyothorax, page 151). After 
the costal pleura is incised a large aneurysm needle is introduced 



208 



Intrathoracic Diseases. 



through one of the pleural incisions and conducted underneath 
the costal pleura to the other. With strong silk sutures the 
tissues, containing fascia, muscles, periosteum, costal pleura, 
and intercostal arteries, are ligated close to the surface of the 




Fig. iio. — Skiagraph of Area or Lung-abscess. 

rib. Then a vertical incision is made through the tissues 
between the two ligatures, thus creating a wide opening (Fig. 
91). By retracting the wound-margins forcibly the skin in- 
cision can be utilized for the resection of the rib above. If, as 
it rarely occurs in these cases, adhesions should be absent, the 



Opening of Abscess by Cautery. 209 

lung may collapse, so that it is found impossible to draw it 
forward, in which event the final incision has to be deferred 
for a day or more. When the lung moves freely beneath, it 
is essential to shut off the pleura by packing gauze tampons 
around the margins in order to prevent infection from the 
escaping pus. As a rule, this procedure renders suturing of the 
pleura to the lung unnecessary, as well as the artificial formation 
of adhesions by the use of caustics. If the abscess is located 
superficially, infection of the pleural cavity might also be 
caused by the stitch canals. 

The further steps must be taken with great care and 
patience. Should palpation of the pulmonary area have failed 
to give information, an exploratory needle of moderate size may 
be slowly pushed into the lung (see Figs. 80 and 82). If neces- 
sary, this must be repeated at different points. Should the focus 
not be reached by the needle, the pulmonary pleura must be 
carefully divided and the thin, slightly red-heated point of a 
Paquelin cautery thrust into the suspected portion. The 
author found it advisable to construct a thin director, made 
of platinum, which fits round the heated platinum tip of the 
Paquelin cautery, just as a stylet fits to a trocar. After the tip 
and encircling director have perforated the lung tissue, the tip 
is withdrawn and the director left in situ to ascertain whether 
any pus appears at the groove of the director. If so, a small 
artery forceps is introduced and the opening gently dilated. 
The great advantage of the Paquelin cautery is its preventing 
infection, while the exploratory needle is apt to cause it. 

In those cases where, after exploratory resection, the costal 
pleura appears to be especially thin, and where at the same 
time no adhesions are present, the membranes not being 
immobilized by adhesion-formation, pneumothorax may form 
as soon as the pleural sac is opened. Then the opening must 
either be packed quickly or the pleurae sewed together. As 
to the value of the Sauerbruch cabinet in such cases see above. 



210 Intrathoracic Diseases. 

In one of the author's cases the lung collapsed as soon as the 
pleura was incised, the patient becoming cyanotic, the res- 
piration shallow, and the pulse imperceptible. He was 
virtually given up, but after thorough packing with sterile 
gauze and the administration of stimulants he rallied. 
Although it seemed desirable to defer pneumotomy for a few 
days the condition of the patient was so bad that the opening 
of a large gangrenous focus was undertaken on the following 
day. But the patient succumbed to sepsis. 

The pleural suture should be rather extensive, the under- 
lying pulmonal tissue to be seized as well as the soft tissues 
in the wound of the chest-wall. Sometimes the pulmonal tissues 
are brittle, so that the stitches may tear. To stop up the punc- 
ture holes Tiegel 1 saturated the silk sutures with iron chlorid, 
thus utilizing the coagulation of the blood. The same author 
recommended to place two " scaffold threads" deep in the lung, 
one on each side of the incision and parallel to the surfaces 
which were expected to be approximated. These sutures were 
then passed around these and knotted. Tiegel claims that 
tearing of the pulmonal tissue, even when brittle, was obviated. 

After the cavity is exposed, no irrigation or exploration 
with the finger is advisable, since procedures of this kind might 
provoke haemorrhage. A narrow strip of iodoform gauze is 
carefully introduced into the cavity. The whole is then 
once more thoroughly cleaned, examined, and packed with 
iodoform gauze, and finally protected by a large piece of moss- 
board. The dressing need not be changed more frequently 
than every second or third day, unless there should be signs 
of retention of pus. It is advisable to tell the patient to blow 
at intervals with his mouth and nostrils closed, which helps to 
evacuate the purulent discharge. 

The patient should get up after a few days if possible. 
During the early period of the after-treatment small doses of 

1 "Zur Technik der Lungennaht," "Munich Medical Weekly," No. 46, 1905. 



^Etiology of Gangrene of Lungs. 211 

morphine are administered for the purpose of immobilization, 
especially when cough is present. If the pulse be weak, stro- 
phantus and caffeine may be added. Nourishment must be 
given frequently and in small quantities at a time. 

Anaesthetics should be used only if the pulse be strong 
enough, which in most cases of lung abscess must be regarded 
as an exceptional circumstance. Ether being contraindicated 
in respiratory disturbance, only chloroform can be employed ; and 
attention needs not be called to the danger to which the use of 
this paralyzing drug subjects the heart. Since, for a well-trained 
surgeon, the operation does not take very long, it would be better 
to use ethyl chloride, or Schleich's infiltration method, and also to 
administer a morphine in j ection before the operation . If chloro- 
form is employed, only a few drops should be poured into the 
mask at a time, and the pulse, the respiration, and the color 
of the face be carefully watched. If a general anaesthetic be 
employed at all, which facilitates matters, the author prefers 
ether in spite of its disadvantages. 



GANGRENE OF THE LUNGS. 

Gangrene of the lungs is primarily due to invasion of sapro- 
phytic bacteria into the lungs. They gain access either by 
being suspended in foreign bodies of an organic nature, like 
food particles directly, or by entering later, after the foreign 
body has settled there. It is self -understood that patients 
afflicted with inflammatory or ulcerating processes in the mouth, 
pharynx, or larynx are especially inclined to the aspiration of 
decomposing elements. The same applies to carcinoma of 
the tongue, pharynx, larynx, oesophagus, and stomach. Frac- 
tures of the mandible which are not well immobilized, and 
where the oral cavity is not kept clean in a most scrupulous 
manner, may also give the impetus to such a fatal complication. 

The fact that patients emaciated by one of the precursory 



212 Intrathoracic Diseases. 

affections mentioned, also aged persons and alcoholics, are 
particularly liable to acquire pulmonal gangrene is one of its 
most important features. The direct type is the most frequent. 

The secondary type of pulmonal gangrene is caused by 
pre-existing affections of the lungs, like fetid bronchitis. If 
in pneumonia, bronchiectasis, or pulmonal tuberculosis a new 
putrid infection takes place, gangrene may be caused in an 
indirect way. To necrotic decubitus, suppurating caries, 
puerperal processes, and similar conditions gangrene of the 
lungs may also be due. 

Pulmonal gangrene is most frequently found in the lower 
lobe, and especially on the right. Here it may be circum- 
scribed as well as diffuse. There the pulmonal tissue has 
changed to a grayish-green mass the odor of which is characteris- 
tically penetrating. (The author has seen some of his best 
nurses faint on account of this odor.) 

It is especially the expectoration of the fetid secretion from 
such necrotic foci which points to the presence of pulmonal 
gangrene. The sputum is profuse, the daily amount being 
from 150 to 500 ex. It contains various types of bacteria. 
The pathognomonic proof is furnished by the presence of 
fragments of pulmonal parenchyma. 

The prognosis of gangrene of the lungs, which was regarded 
as most unfavorable before the aseptic era, has materially 
changed for the better. It depends upon the aetiology of the 
various types, the embolic as well as the bronchiectatic form 
of gangrene being inauspicious. As long as the process is of a 
circumscribed nature the chances are naturally more favorable. 
The mortality of the present time shows 31 per cent, only in 
cases where radical pneumotomy was performed. This result 
would be still more favorable would not, in the cases mentioned, 
a number of aggravating circumstances have coexisted, viz., 
multiple foci, bilateral gangrene, and association with embolic 
processes, inflammation, or abscess of the brain. 



Bronchiectasis. 213 

In order to be able to approach the cavity as directly as pos- 
sible, extensive exploratory resection of the chest-wall should pre- 
cede its exposure. This is so much more necessary as there are 
often small cavities grouped around a large one, which are more 
or less connected with the latter. It is self-understood that 
they must also be made accessible to direct surgical interference. 
The best guide for localization is the Rontgen method, see 
page 225. All necrotic tissue must, of course, be completely 
removed and the cavity packed with iodoform gauze. Irriga- 
tion must not be used during the after-treatment, which is vir- 
tually the same as that of lung-abscess (see page 210). 



BRONCHIECTASIS. 

Bronchiectasis is, as a rule, not a disease per se, but a conse- 
quence of various affections of the lungs or bronchi. From an 
anatomical point of view a cylindrical and a sacculate form is to 
be distinguished. (Compare anatomy of the bronchi, page 238) . 

The cylindrical bronchiectases represent regular dilatations 
of the bronchial tubes, due to bronchial catarrhs of long dura- 
tion, as they are found in emphysema, whooping-cough, and 
sometimes in pulmonal tuberculosis. Atrophy and ulceration 
of the bronchial walls, caused by the cough attacks, probably 
give the first impetus. The diagnosis of this form is uncer- 
tain, copious (500 to 900 c.c. during one cough-attack) and 
thick muco-purulent sputa, which show a stratified character 
when standing stagnating in a glass, being the main factors 
pointing to its existence. 

In the sacculated type, which confines itself to a limited 
part of the bronchial area, the dilatation assumes a globular 
or oval form. The glandular mucous membrane, the muscu- 
lar fibres, and the elastic elements undergoing complete atrophy, 
the bronchial wall loses its character entirely, so that the cavity 
is lined with a thin membrane only. 



214 Intrathoracic Diseases. 

in emphysema cavities of this nature may be surrounded 
by normal lung-tissue, but in the great majority of cases they 
are situated in the midst of indurated shrinking pulmonal tissue, 
which often is due to a preceding pleuritis. The sacculated 
type is unilateral, as a rule, and its seat of predilection is the 
lower lobe. 

In differentiating bronchiectasis from tuberculosis it should 
be considered that the bronchiectatic patient appears pale and 
more or less cyanotic, but never cachectic, his panniculus 
adiposus being abundant, as a rule. As in fetid bronchitis, 
the ends of the patients' phalanges are club-shaped. As long as 
there are no complications fever remains absent. Auscultation 
and percussion do not reveal any essential diagnostic points out- 
side of proving the presence of a cavity. But the Rontgen 
method differentiates and localizes the cavity under favorable 
circumstances (see section on the Rontgen method, page 250). 

The prognosis of bronchiectasis is less favorable than that 
of pulmonal gangrene, the percentage of complete recoveries 
being only thirty, while that of the partial recoveries amounts 
to the same rate. It is, of course, the type and the extent of 
the cavity which determines the prognosis. Thus, it can be well 
appreciated that the large ectasies of the lower lobes give a 
good prognosis, since they can be easily reached, a resection of 
one piece of a rib generally giving sufficient access. In the 
greater majority, however, mobilization of the thoracic wall 
by multiple rib-resection is preferable. The mortality 7 rate 
in such cases amounts to 6 per cent. only. This result is un- 
doubtedly due to early and radical interference. 

The after-treatment is the same as in lung -abscess (see page 
210). 

ECHINOCOCCUS OF THE LUNGS. 

As is generally known, echinococcus-disease is produced 
by the taenia echinococcus, a parasite whose domicile is in the 



Echinococcus of the Lungs. 215 

intestines of the dog, sometimes perhaps also of the cat. Its 
length is four millimetres. It has four joints, the posterior of 
which is larger than the remaining three together. The 
implantation of this parasite causes the formation of hydatids, 
which grow into cysts and secondary proliferative cysts in 
various organs of the human body, particularly the liver. 

The knowledge of the echinococcus disease dates as far 
back as to the time of Hippocrates, who described a "jecur 
aqua repletum" which would open into the abdominal cavity. 
The same author speaks of an operation on an echinococcus 
cyst, before which operation he advised to produce adhe- 
sions between abdominal wall and cyst by the use of artificial 
moxae. The true parasitic origin of the disease, however, 
was not demonstrated until Goze, in 1782, recognized the 
characteristic heads and hooklets of the taenia. 

The echinococcus disease is found in all parts of the world ; 
yet with the exception of Iceland, some parts of Australia 
(Victoria and Tasmania), and the vicinity of Irkutsk (Russia), 
where it is endemic, it is but rarely observed. Especially 
rare is the echinococcus disease in this country, which explains 
fully why the American literature on this most interesting 
subject is so very scant. 

The predilection of the echinococcus for the liver is quite 
natural. The vena portae leads it by the shortest and broadest 
route, just as it carries a pyogenic embolus from an infected 
focus. The echinococcus is found much less frequently in 
other organs, as, for instance, in the medulla of bones, the pleurae, 
the spleen, the intestine, the heart, and still more rarely in the 
lungs. The literature of echinococcus of the lung is meagre, 
therefore. The author has observed three cases, two of these 
being described in "The Journal of the American Medical 
Association," November 19, 1898. 

Whether the parasite in the author's cases was originally 
implanted in the lungs (primary echinococcus of the lung), 



216 Intrathoracic Diseases. 

or invaded indirectly from the pleura or liver by slow perfor- 
ation, is not fully evident from the previous histories. While 
in one case the localization of the abscess, which had been 
incised two years ago, might point to its origination in the liver, 
the symptoms of an affection of the lungs were predominant 
from the early beginning of the disease. That well-pro- 
nounced symptoms were absent for a long period could be 
explained by the slow growth. In the initial stage frequent 
cough and bloody expectoration are found, as a rule, while the 
physical signs are not yet marked. Exploratory aspiration 
is contraindicated in pulmonal echinococcus, pneumotomy 
being the proper procedure for diagnostic as well as thera- 
peutic purposes. 

The resume of the diagnostic points may be condensed as 
follows: (i) Whenever the symptoms of a chronic affection of 
the lungs become apparent, and pneumonia, circumscribed 
effusions, pyothorax, and infectious diseases (particularly tuber- 
culosis) are to be excluded, the possible presence of echinococcus 
should be thought of, especially so when at a later stage there 
is violent cough and expectoration of blood and pus of a most 
offensive odor. (2) In those rare cases where the examination 
of the sputa fails to show the characteristic elements of the 
parasite, it should be considered that at the early stage of pri- 
mary echinococcus the lines of dullness are irregular according 
to the shape of the cysts, and sharply pronounced, while later, 
when it comes to the formation of an abscess cavity, they 
are replaced by tympanitic sounds. • Accordingly there is also 
no abnormal temperature at the beginning, while later the 
characteristic irregular temperature-curve points to pus reten- 
tion. (3) Sometimes there is an expansion of the thoracic 
wall and a dilatation of its veins. If the abscess wall ap- 
proaches the chest-wall, bulging of the intercostal spaces 
becomes noticeable. 

From the author's cases it appears that the diagnosis of 



Actinomycosis of the Lungs. 217 

echinococcus of the lung is usually difficult. Its rarity pre- 
vents its general and thorough study, but it can fairly be 
assumed that it is more frequent than is supposed, because 
on account of its difficult recognition it is often mis- 
taken for an altogether different disease. With our better 
means of investigation and our greater zeal, this disease will 
in the future be more frequently detected, and pneumotomy, 
the only proper therapy, more often resorted to. 

As to Rontgen examination, see the section on that method 
(page 250). 

As to the technic of the operation, see section on rib resection 
and on lung abscess (pages 151 and 210). 



ACTINOMYCOSIS OF THE LUNGS. 

The ray fungus, actinomyces bo vis s. hominis, was discov- 
ered by the author's immortal teacher, Bernhard von Langen- 
beck, in the vertebral abscess of a man, in 1845. The favorite 
domicile of this peculiar fungus is the maxillae of cattle, in which 
it causes indurated tumor-like masses, which undergo softening 
and suppuration. In man the lower jaw is most frequently 
also the primary focus of the disease, which extends continually 
into the adjacent tissue and internal organs, like the lungs, the 
pleurae, the heart, the liver, the kidneys, the intestines, and the 
brain. The actinomyces can be cultivated on agar by cutting 
off oxygen, in which event yellowish- white colonies are formed. 
But if the air has free access, an ochre-colored appearance is 
obtained. Pure cultures injected into the cavum peritonei of 
rabbits produce typical actinomycosis. The fungus stains well 
with the aniline dyes and by the method of Gram. 

It gains access to the lungs by direct aspiration or by 
using wheat or fragments of carious teeth as a vehicle. 
Sometimes it reaches the lungs or the pleura indirectly by 
transmigrating from an inflamed oesophageal area alongside 



218 Intrathoracic Diseases. 

the spinal column and the thoracic wall and causes destruc- 
tion and cavity formation. 

After having invaded the lungs, the actinomyces strives 
to reach the pulmonal surface and finally infects the pleura. 
In making its way to the pleura the fungus causes the for- 
mation of fibrous adhesions. At the same time effusions are 
found which may be of a serous or a purulent character. Then 
it will resemble serothorax or pyothorax so much that it is 
mistaken for any of these conditions in the majority of cases. 
The diaphragm, pericardium, and mediastinum are generally 
left free. The infiltration of the thoracic wall may finally 
soften, thus producing fistulous tracts, from which grayish or 
yellowish sero-pus, mixed with the characteristic actinomycotic 
granula, is discharged. Primary actinomycosis of the lungs 
represents 20 per cent, of all cases. 

The diagnosis is based upon the presence of the granula. 
Hodenpyl found that in 18 of 34 cases the microscope made 
the diagnosis at an early stage. At the incipient stage tuber- 
culosis may be thought of, which is justified by the presence 
of dyspnoea, continuous fever, night-sweats, haemoptoe, and 
the emaciation. But the continuous absence of tubercle bacilli, 
while the destruction process is extending, shows that there 
must be an entirely different aetiology. If there be much fibrous 
infiltration, osteosarcoma of the ribs, the sternum, or scapula 
may be thought of, temporarily, until the formation of fistulas 
clears the situation. Even when the granula are absent, the 
fact that the thorax appears to be swelled on one area and re- 
tracted on another, the induration of the soft tissues, the physical 
signs of pleural effusion while the aspiratory needle proves the 
absence of such, the slow process, the absence of electric fibres 
and of tubercle bacilli, should point to the peculiar nature of the 
disease. 

The prognosis is doubtful. Surgical interference is suc- 
cessful in the incipient stage only. Literature up to date 



Pulmonal Tuberculosis. 219 

knows only of five complete recoveries. Schlange 1 reports 
three recoveries. 

The operation consists in free opening by extensive rib- 
resection (see section on the technic of rib-resection) and the 
extirpation of the degenerated tissue, especially the thickened 
fibrous swards. Lung cavities must be drained (see section 
on lung abscess). Prevertebral and perioesophageal foci can 
be reached by the surgical knife under extraordinary circum- 
stances only. At the lower portions of the oesophagus Ender- 
len's method for the opening of the mediastinum can be 
utilized. 2 

TUBERCULOSIS OF THE LUNGS. 

The results of operations performed for this most frequent 
of all diseases are not very encouraging. Still there is a num- 
ber of cases in which cures were effected. Surgical interfer- 
ence should therefore not be condemned, as is frequently done. 
Of course, it should only be undertaken if there are circum- 
scribed foci. If there is as large a number of foci as is illus- 
trated by Fig. in, no chances for an operation are to 
be thought of. Sonnenburg demonstrated a patient, before 
the German Surgical Society, who had recovered completely 
after the extirpation of a tuberculous focus in the lungs. Mur- 
phy reported 26 temporary cures among 47 patients operated 
upon in the same manner. Tufher and Lawson published 
the most encouraging results, but other surgeons were less 
fortunate. 

There are three drawbacks regarding the indications for 
the operation: 

1. Its danger. 

2. The uncertainty of a detailed diagnosis, although the 
Rontgen rays give us good chances for localizing the foci. 

1 " Zur Prognose der Actinomycose," "Archiv fur klin. Chirurgie," 1892, Bd. xliv, 
p. 870. 

2 Enderlen: "Contribution to the Surgery of the Mediastinum," "Deutsche Zeit- 
schrift f. Chir.," Bd. lxi. 



Intrathoracic Diseases. 




j 



Operation in Tuberculous Foci. 221 

3. The possibility of recovery by non-operative means. 

In its incipient stage the disease is often cured by medical, 
that is, by climatic, dietetic, and mechano-therapeutic, means, 
while in late stages it has generally passed beyond the hope 
of benefit from operation. 

The best results are obtained in cases of mixed infection 
where continuous septic absorption is produced. There the 
stagnating contents of the cavity are promptly removed by 
drainage, and if the fever -was due to the absorption it dis- 
appears after further decomposition is thus prevented. Natur- 
ally the general condition improves accordingly. A fair result 
may also be obtained in those types of pulmonal tuberculosis 
where tissue-necrosis has not yet taken place, or where no such 
tendency exists. 

The operation may also be indicated in case of excessive 
and repeated haemorrhage. The more radical extirpation of 
a tuberculous focus, as performed by Turner, is extremely dan- 
gerous; still, once in a while such risky steps are followed by 
a cure. In one of his cases Turner incised the pleura below the 
second rib and freed it from the ribs as far as he could, thus 
virtually establishing a pneumothorax outside of it. After 
having palpated the indurated focus in the apex, he opened the 
pleura and pulled the lung tissue forward with a large grasping 
forceps. Then he resected the whole portion. Drainage was 
omitted. The patient was shown in excellent condition at the 
Societe de Chirurgie twelve days after the operation and was 
reported cured four years afterward. 

Mobilization of the thoracic wall above the cavity and par- 
tial decortication of the pleurae is a most important adjunct in 
the healing process, as it favors diminishing the extent of the 
cavity by the collapse of its indurated roof, thus also causing 
relaxation of the overextended tissues, and thereby being re- 
lieved from the continuous straining due to the respiratory 
motions. 



222 Intrathoracic Diseases. 

Even the infiltrated tissues situated below the cavity are 
favorably influenced by extensive resection of the thoracic wall 
as soon as they become thus immobilized. 

On an average five to six ribs should be resected, each 
one of them to the extent of five inches at least. The fric- 
tion as a predisposing moment for tuberculosis of the apex 




-Relapse after Extirpation or Larynx and Upper Portion of 
Trachea for Tuberculosis. 



(see page 205, final sentence) suggests mobilization of the first 
rib if there be a focus. This can be done by simple division 
of the cartilage, the scaleni and subclavian muscle preventing 
reunion of the fragments. 

The technic of the operation is practically the same as 
described in the section on lung abscess (page 210) (see on 
pyothorax also, page 151), and should always be preceded by 



Intrathoracic Tumors. 223 

the resection of a few ribs. The lung tissue should be invaded 
by Paquelin's cautery while using the trocar-director advised 
by the author. 

Injections of iodoform-glycerin into the cavities have also 
been tried by the author with an encouraging result in two 
cases. Where no stagnation of the secretion exists, this mode 
of treatment should be given a trial. (See section on aspira- 
tion, page 93.) 

If tuberculous cavities form secondarily, the chances for 
operation are very unfavorable. Fig. 112, for instance, illus- 
trates a case of primary tuberculosis of the larynx treated 
by extirpation. The patient, a man of thirty-eight years, did 
well for nine months, during which time he carried a canula, 
when tuberculous granulations showed in the tracheal canal. 
At the same time the signs of abscess formation in the lungs 
appeared, to which the patient finally succumbed. 

INTRATHORACIC TUMORS. 

A correct diagnosis of tumors of the lungs is still very 
difficult, pleural effusions often being mistaken for malignant 
growths, and vice versa. 

There are benign growths in the lungs as well as malignant. 
The benign growths are osteoma, enchondroma, fibroma, and 
lipoma. They need no consideration from a clinical point of 
view, since they are not only rare but of such small size, as a 
rule, that they give rise to no disturbances. Most of them 
were accidentally detected during autopsy. 

Dermoid cysts, which should properly be called tera- 
tomata, generally originate from the mediastinum and invade 
the lungs. They contain hair, as a rule, are found especially 
in young individuals, and are characterized by their slow 
growth. They gradually cause symptoms of compression of the 
lungs and displacement of the heart. Finally they may cause 



224 Intrathoracic Diseases. 

a protuberance of the ribs. In some cases they perforate 
into the bronchi, suppuration taking place then. Sometimes 
a fistulous tract forms at the outer surface of the chest-wall. 

Under favorable conditions enucleation must be attempted. 
In most instances the cyst could be removed only partially. 
Von Eiselsberg 1 succeeded in enucleating large dermoid cysts 
in their entirety. 

The malignant growths are either sarcomatous or can- 
cerous, the latter being found more frequently than the former. 
Carcinoma of the lungs is generally found in aged persons. 
It is far more frequent in men than in women. Sometimes' 
numerous carcinomatous nodules of the size of a walnut are 
found ; at other times a whole lobe is taken up by the neoplasm. 

The diagnosis is very rarely possible in the initial stage, 
the symptoms being vague. There is more or less pain, 
cough, expectoration, and slight dyspnoea. Later bloody 
serum may be aspirated from the pleural cavity. Then the 
symptoms of compression (atelectasis of some pulmonary areas 
and bronchial stenosis) become predominant, and in the 
further course of the disease inflammatory symptoms (pneu- 
monia) may supervene. 

The physical signs consist in more or less marked dullness. 
With this a skiagraphic shadow in the plates of the translucent 
area of the normal lungs must correspond. (See Rontgen 
method, page 249.) If there is an effusion in the pleura, as- 
piration in connection with a trocar, which terminates in a 
flexible hook, sometimes reveals tumorous fragments, the nature 
of which is recognized by microscopic examination. 

The sputa contain polymorphous epithelium, which is 
free from pigment. Its size is different and shows marked 
contours and a well-defined nucleolus. Lenhartz regards 
the admixture of large and numerous fatty globules as path- 
ognomonic. 

1 " Zur Therapie der Dermoidcysten des vorderen Mediastinum," " Wiener 
klinische Wochenschrift," xix, 1903. 



Sarcoma of the Lungs. 225 

The prospects of a surgical operation are unfavorable, even 
if the diagnosis is exceptionally made at an early stage. Ront- 
gen treatment should be tried as a palliative measure, hard 
tubes to be selected for that purpose. (See Rontgen treatment 
in the final chapter.) 

Secondary carcinoma caused by metastasis or by continua- 
tion of a mammary growth is considered in connection with 
the primary seat (see section on mammary carcinoma). 

Sarcoma of the lungs is less frequent than carcinoma. 
The predominating type is that of lymphosarcoma, which is 
especially found in miners who inhale dust containing arsenic. 

When the lymphosarcoma originates from the bronchial 
glands and the peribronchial tissue it forms large nodules. 
Primary sarcoma of the lung tissues is extremely rare. 

The clinical symptoms consist especially in the signs of 
compression of the nerves and dilatation of the veins at the 
chest-wall. In lymphosarcoma there is very marked stridor 
caused by the swelling of the bronchial glands. 

In sarcoma association with pleurisy is more frequently 
found than is carcinoma. An effusion generally consists of 
hemorrhagic serum, but may also be purely hemorrhagic. 
E. Frankel maintains that the presence of very large vacuole- 
cells, ten to twenty times the size of leucocytes, is pathogno- 
monic for sarcoma. 

Metastasis is more frequent in sarcoma. Rapid cachexia 
and anaemia also point to sarcoma. 

As far as treatment is concerned, the principles emphasized 
above on carcinoma also apply. 

Partial removal of such sarcomatous or chondromatous 
growths, which originated from the thoracic wall and extended 
into the lung tissue, proved to be successful in some instances, 
while no successful removal of primary sarcoma of the lungs 
is reported as yet. 

The tumors of the mediastinum resemble those of the 



226 Intrathoracic Diseases. 

lungs. They are either benign (fibroma, cyst, dermoid cyst, 
and endothoracic struma) or malignant (carcinoma or sar- 
coma). Their treatment is practically identical with that of 
the tumors of the lungs. Syphilis of the mediastinum is rare 
and must be treated after general antiluetic principles. 

Mediastinals is usually of secondary origin, the inflam- 
mation of adjacent organs continuing alongside the sheaths of 
the carotid or jugularis. Sometimes the pre visceral space 
in front of larynx and trachea, in which abscesses of the thyroid 
gland, the larynx, and the trachea form, is its source. The 
same may be said of the retrovisceral space behind pharynx 
and oesophagus. In favorable cases opening of the abscess 
cavity is indicated. Galen exposed the mediastinum after 
trephining the sternum. The mediastinum posticum is best 
made accessible by removing a transverse process together 
with that portion of rib which is situated below it. 

DIAPHRAGM. 

Surgical diseases of the diaphragm are rare, while con- 
genital anomalies are fairly frequent, diaphragmatic hernia 
being observed in many instances. In these cases an open 
communication between the abdomen and the thoracic cavity 
exists. The symptoms of this malformation are abdominal in 
character. If the diaphragm is absent or if the defect be large, 
the infants are unable to live. 

Perforation of the diaphragm, due to injury and inflamma- 
tory processes, will be dealt with in the section on subphrenic 
abscesses. 

ANEURYSM OF THE THORACIC AORTA. 

The symptomatology of thoracic aneurysm belongs to a 
text-book on internal medicine. As far as differentiation is con- 
cerned, it should be appreciated that aneurysms may be mistaken 



Iodide of Potassium in Aneurysm. 227 

for tumors and vice versa. The Rontgen method has done 
much to elucidate diagnostic points which were obscure before 
its discovery. (See section on thoracic skiagraphy, page 246.) 

The surgical treatment of thoracic aneurysm has so far 
confined itself to the ligation of the two branches of the bi- 
furcation after Brasdor-Wardrop, which of course is a very risky 
procedure, Winslow, however, and Guinard having reported 
favorably on it (Fig. 113). As to the route of access, compare 
Figs. 31, 72, and 78. 

From a theoretical standpoint it does not appear im- 
possible to undertake the removal of a small aneurysmatic 





Fig. 113. — A, Ligature after Brasdor-Wardrop. B, Ligature after Anel. 

sac, if detected early, and to sew up the wound of the ves- 
sel. So far, however, nobody has attempted it. 

A much more reliable method is the injection of gelatine 
after Lancereaux. The administration of drugs (mercury and 
iodide of potassium) has also given good results once in a while. 

The admirable influence of iodide of potassium is illustrated 
in the following case: 

An Italian laborer showed a pulsating tumor at the left 
intraclavicular fossa (Fig. 114). The diagnosis aneurysm of 
the subclavian artery had been made and ligation advised. 
In the meanwhile several skiagraphs were taken that showed 



228 



Intrathoracic Diseases. 



the presence of aortic aneurysm, the supraclavicular tumor 
being only a portion of it. Shortly after iodide of potassium 
was_ administered the supraclavicular tumor disappeared 
entirely (Fig. 115). The size of the aneurysm had considerably 




*m- 



Fig. 114. — Supraclavicular -Projection of Aortic Aneurysm. 



decreased, as was shown by the skiagraph (Fig. 116). In har- 
mony with the anatomic diagnosis is the excellent condition 
of the patient, who has now been under observation for six years. 
It should be borne in mind that the fluoroscope shows 
the normal aorta in the left mediastinum at the first intercostal 



Rontgen Method in Aneurysma Aortae. 229 

space. A sac-like bulging of the arch, showing considerable 
pulsation above this space, points to the presence of aortic 
aneurysm. Vehement pulsation, if there is no sac-like bulging, 
indicates aortic insufficiency. 




Fig. 115. — Supraclavicular Region After Disappearance of Aneurysmatic 
Tumor Illustrated in Fig. 114. 



In a most extraordinary case of aortic aneurysm, illus- 
trated by Fig. 117, it was possible to demonstrate not only com- 
plete atrophy of the sternum down to the xiphoid process, 
and of the sternal portions of the clavicle, but also the over- 
lapping of the heart over the parasternal line and downward 



230 



Intrathoracic Diseases. 




From Beck's " R5ntgen-Ray Diagnosis, 1 ' copyright, 1904, by D. Appleton and Company. 



Fig. 116. — Aortic Aneurysm, Illustrated by Figs. 114 and 115, Showing Im- 
provement AFTER THE ADMINISTRATION OF IODIDE OF POTASSIUM. 



Early Signs of Aortic Aneurysm. 



231 



displacement of its apex. The patient, an architect, aged 
thirty-nine years, German by birth, single, gave the fol- 
lowing family history: Father died suddenly when sixty- 




five years of age; mother also died suddenly when sixty. His 
only brother died of typhoid fever at twelve. There were 
no sisters. 



2 3 2 



Intrathoracic Diseases. 



The patient denied lues, and the examination did not contra- 
dict his statement. Gout and chronic nephritis, as well as any 
erotic excesses, were to be excluded. He was always well until 
five years ago ; then, after lifting an excessively heavy weight, 
he noticed a small protuberance on the left side of his neck; 




Fig. 



118. — Aortic Aneurysm Causing Disappearance or the Sternum and oe the 
Sternal Portions of the Clavicle. (Compare Fig. 117.) 



this grew constantly, invading at last the whole anterior surface 
of the neck and the upper portion of the chest. It is highly 
probable that the exertion in lifting caused an enormous 
increase in the circulatory pressure, followed by an over- 
extension, and probably a laceration of the tunica intima 
and media. 



Late Signs in Aortic Aneurysm. 233 

Shortly after this he was admitted to a hospital, where 
he was treated for torticollis, as he states, for five weeks. 
During that period slight dysphagia and hoarseness had been 
present. He recovered again so far as to regard himself as 
well for an entire year. Then a " severe attack of malaria " 
induced him to seek hospital treatment again. At that time 
the tumor had not exceeded the size of a large apple. The 
hoarseness was considerable then. After having improved 
again he left the hospital, and for eighteen months after had 
been under medical treatment with great temporary success. 
Then he began to suffer from slight dizziness, with constric- 
tion of the throat and chest, slight dysphagia and hoarseness 
also recurring. 

On October 31, 1898, when the patient entered St. Mark's 
Hospital, the author saw him for the first time. The 
tumor had reached an enormous size then, extending over the 
sternum, the sternal portions of the clavicles, and the whole 
anterior surface of the neck, the diameter of the latter portion 
being 7! inches. The constant pressure of the tumor had 
caused complete atrophy of the adjoining osseous structures, 
so that no visible trace was left of the sternum or of the ster- 
nal portions of the clavicles. 

The examination of the heart both by percussion and by 
the Rontgen method revealed hypertrophy of the left ven- 
tricle. The apex-beat was felt in the sixth intercostal space 
an inch beyond the mammillary line. Above the jugulum 
and in the right parasternal line a diastolic as well as a systolic 
murmur were noticed, the latter being more distinct at the 
systole. On placing the hand gently on the tumor vibration 
could be felt. 

The lungs were normal. No cough was present. Some- 
times, especially after any muscular exertion, there was 
dyspnoea. The respiration was 20 to the minute, the pulse 
78, the temperature oscillated between 97 and 98 F. The 



234 



Intrathoracic Diseases. 



pulse of the right radial artery was weaker than that of the 
left, and lagged behind it appreciably. There were no signs 
of arteriosclerosis. The voice was clear and its resonance 
simply remarkable, the previously existing hoarseness un- 
doubtedly having been due to pressure paralysis of the recur- 




Fig. 



-Incipient Stage oe Sternal Atrophy due to Aortic Aneurysm. 



rent nerve. The dysphagia, caused by pressure upon the 
oesophagus, was very moderate on admission. 

The subjective disturbances of the patient were then 
insignificant. He had a fine appetite and attended to his 
business for the preceding four weeks. 



Surprising Euphoria in Aortic Aneurysm. 235 



The pulsation was unusually moderate in comparison to 
the large size and hardness of the tumor, a circumstance 
which pointed to the presence of abundant coagulation. It 
must also be assumed that the aortic wall formed by adven- 
titia and the abundant proliferation of connective tissue had 




Fig. 120.- 



-Advanced Stage of Pressure-atrophy of Sternum and Third to 
Fifth Ribs due to Aortic Aneurysm. 



become so much fortified that the blood could discharge again 
from the subadventitial sac in the peripheral portion to the 
proper vascular channel. To these fortunate circumstances, 
the coagulation as well as the patency of the vascular channel, 
the surprising euphoria was attributed. 



236 Intrathoracic Diseases. 

As mentioned above, the skiagraph (Fig. 117) showed com- 
plete atrophy of the sternum down to the xiphoid process, and 
of the sternal portions of the clavicles. The heart overlaps the 
parasternal line, and its apex shows a slight displacement 
downward. Its oval shape is distinctly recognizable, and is 
well demarcated from the aneurysm, the intrathoracic extent 
of which is enormous. 

Thus it can be seen that often more reliable information 
as to type, shape, and size of intrathoracic tumors can be 
obtained by skiagraphy than by percussion. There can be 
no doubt that the Rontgen rays enable us to recognize aneu- 
rysms at their earlier stages, so that frequently a series of 
prophylactic measures can be taken which may counteract 
any further aneurysm formation. The therapy being under 
perfect control, it can be ascertained whether under treat- 
ment either improvement, arrest, or still further expansion 
may take place. 

The patient was subjected to Barwell's diet and to 
gelatine injections after the manner of Lancereaux for 
two months. The injections were well borne, except on one 
occasion, when a slight rise of temperature followed and 
persisted for three days. During that period the patient's 
general condition was considerably affected. There could 
be no doubt, however, that the tumor decreased in size; the 
hoarseness disappearing entirely, and the subjective condition 
of the patient being much improved. 

In July, 1899, the patient died after three days of an acute 
attack of pneumonia. The autopsy showed no rupture of the 
enormous sac, but suppuration of the bronchial glands, prob- 
ably caused by the gelatine injections. The specimen ob- 
tained at the autopsy proved the correctness of skiagraphic 
representation. 

The gelatine is prepared by dissolving 2 grammes of white 
gelatine in 100 grammes of hot water, to which \ gramme of com- 



Texture of Trachea. 237 

mon salt is added. This solution is sterilized in a kettle by ex- 
posing it to full steam for fifteen minutes. Before use it is to be 
warmed in water which has a temperature of ioo° F. Under 
thorough aseptic precautions the whole amount is injected 
below the integument near the aneurysm. The injections 
are repeated every second day; at least 12 are required. The 
patient must remain in bed while under treatment. 

Fig. 119 shows the incipient stage of atrophy of the 
sternum due to aortic aneurysm in a man of sixty-two 
years. Temporary relief was caused in his case by gelatine 
injections. 

Fig. 120 illustrates a more advanced condition, the third, 
fourth, and fifth rib becoming atrophied by the pressure 
exerted through a large aortic aneurysm. The sternum had 
almost entirely disappeared. This patient refused to submit 
to the injection treatment, because his subjective condition 
was surprisingly good. 

ANATOMY OF TRACHEA AND BRONCHI. 

The trachea (aspera arteria, rpa^u aprrjpia, " rough wind- 
pipe") (Fig. 121) is virtually the cartilaginous and cylin- 
drical continuation of the larynx, as the oesophagus is the con- 
tinuation of the pharynx. It is a stiff and resistant tube, whose 
posterior surface is soft and flattened, and has the oesophagus 
behind it. The softness and resistance of the posterior aspect 
of the trachea are dictated by the fact that during the act of 
swallowing the oesophagus is distended by the bolus, which 
necessitates the yielding of the wall in front of it. The trachea 
measures from ten to twelve centimetres in length and tw r o and 
a half centimetres in width. It extends from the lower border 
of the fifth vertebra. In descending vertically down to the 
thorax it is covered by the deep fascia colli, the thyroid gland, 
and below this by the lower thyroid veins. Behind the incisura 
semilunaris sterni it descends to the third thoracic vertebra, where 



2 3 8 



Intrathoracic Diseases. 



it is divided (bifurcation) into two divergent branches, called 
the bronchi, each one entering one lung. The right bronchus 
is shorter and wider than the left and also more transverse. 
Each bronchus is divided into as many branches as there are 
lobes, viz., two on the left and three on the right side. In 
order to be protected against any compression from without 



First ring of trachea 




Right pulmonary 
artery 



\pl// 




Position of thyroid isthmus 



Level of sternum 



Last ring of trachea 



Left pulmonary 
artery 



Left bronchus 



Fig. 121. — Anterior View of the Larynx, with the Trachea and Bronchi.- 
(Morris, after Bourgery.) 



the trachea is stiffened by a series of imperfect cartilaginous 
rings of the hyaline type. They are sixteen to twenty in number, 
are embedded in a fibro-elastic membrane, and connected by 
unstriped muscular fibres only at their posterior surface. In 
other words, there is a defect behind, the rings being open there 
and having the appearance of a c, the open part of this letter 



Foreign Bodies. 239 

corresponding to the posterior wall of the ring. The shape and 
width of the trachea and bronchi are dependent upon those of 
the cartilages, which are connected in a continuous series 
by a fibrous membrane, that permits of extension and shorten- 
ing of the tracheal tube. The interior of the trachea is lined 
with columnar ciliated epithelium and elastic fibres. Where 
the cartilaginous substance is absent lymphoid tissue is found. 
The bronchi show the same structure, the left bronchus con- 
taining nine to twelve cartilaginous rings, while the right has 
only six to eight. 

FOREIGN BODIES IN THE RESPIRATORY PASSAGES. 

Literature on this subject has increased considerably and 
the statistics of operations show much improvement. The 
greatest impetus was given by the Rontgen method, which 
brought new light into this formerly unpromising field. 

As to general symptoms and treatment of foreign bodies, 
which enter the thoracic cavity through the chest- wall, the 
author refers to the section on penetrating wounds of the chest, 
page 83. 

The foreign bodies, which enter the bronchi, especially the 
right bronchus, by the natural passages, are bullets, coins, 
bodies of irregular shape (fragments of glass or bone), beans, 
grains of corn, melon-seeds, coffee-beans, etc. The greater 
width of the right bronchus causes a stronger current of air to 
the right lung, which explains the fact that in the far greater 
majority of cases the right bronchus becomes the seat of a 
foreign body. 

The symptoms depend upon the size and shape of the 
foreign body to a large extent. Irregular bodies will soon be 
anchored, while globular ones obstruct the bronchus, so that 
there is no access of air to it. Whether the body moves or 
not will also have an influence upon the character of the symp- 
toms. 



240 Intrathoracic Diseases. 

The early symptoms of a foreign body in the bronchi are : 
More or less local pain and diminution or even disappearance of 
the breathing sounds at the area concerned. Dullness on 
percussion may not appear at first, but will manifest itself as 
soon as there is infiltration and atelectasis. Vocal fremitus is 
nearly absent. The sputa show bloody streaks. Sometimes 
when erosion of a vessel has taken place there may be hae- 
moptysis. More or less dyspnoea is always present. If the 
foreign body moves, violent attacks of cough are observed. 
There is a sensation of suffocation then, which is accompanied 
by nausea or vomiting and sometimes even by temporary un- 
consciousness. 

In many instances these symptoms may not become marked 
in the beginning, so that if the anamnesis is not reliable, 
doubts as to the correctness of the diagnosis may arise. These 
doubts can at once be removed by resorting to the aid of the 
Rontgen method, and it is in fact a crime to endeavor to ascer- 
tain the fact by further expectant procrastination, which means 
nothing less than death for the unfortunate patient. Foreign 
bodies always cause grave symptoms sooner or later, and they 
should therefore be extracted at the earliest possible moment. 
So far there is only one case known in literature, in which the 
aspirated fragment of a broken tracheal canula became 
encysted, after having caused severe symptoms for two months 
(Blumenthal). 

According to Hoffmann, 1 a foreign body should be thought 
of, when there is: (i) Circumscribed broncho-pneumonia and 
bronchiectasis in the right lower lobe; (2) when there are signs 
of abscess-formation without apparent cause; (3) when aged 
people present signs of peculiar somnolence, while the respir- 
atory tract shows symptoms of disturbance. Reports show 
that many times there are grave symptoms in the beginning, 
which disappear again, until years afterwards gangrene or 

^othnagel's "Special Pathology and Therapy." 



Symptoms of Foreign Bodies. 241 

lung abscess begins to form. (See respective sections, pages 
206 and 211.) 

The author observed cases in which a healthy man, while 
at dinner, suddenly became cyanotic, struggled with his arms 
and fell on the floor, where he remained unconscious for less 
than a minute, then rallying so much that the intense 
shock was soon forgotten. There a fish-bone had passed the 
glottis and obstructed the larynx for a moment, until it moved 
further down into a bronchus, which brought temporary 
relief. He also observed the case of a man, who was treated 
by a laryngologist for several months, without manifesting any 
alarming symptoms, although a large fragment of a tracheotomy 
canula was in the bronchus, from which it was expectorated, 
while the author introduced the bronchoscope. 

How misleading the symptoms often are, is illustrated by 
the author's report on foreign bodies in the oesophagus and 
trachea in the "New Yorker medizinische Wochenschrift,' , 
April, 1892. 

As mentioned before, the treatment is either bloodless or 
operative. 

The bloodless methods are: Administration of emetics, 
preferably by subcutaneous injections of the muriate of apo- 
morphine, special positions and manipulations, or extraction 
of the foreign body under the guidance of the bronchoscope. 

The operative methods are: Inferior tracheotomy, intra- 
thoracic tracheotomy above the bifurcation, bronchotomy from 
the posterior mediastinum, and pneumo-bronchotomy. 

As to special positions, it may be said that an effort can be 
made to dislodge the body by strapping the patient, especially 
if he be an adult, to a swinging platform, tilted head downwards. 
The head, may reach the floor. Forced expiration should , 
be advised, while inspiration must be done slowly and super- 
ficially. These procedures have a chance of success, as long 
as the foreign body is still movable. 
17 



242 



Intrathoracic Diseases. 



The bronchoscope was introduced into practice especially 
by the untiring efforts of Killian, and has proved to be of great 
value. In a number of cases fragments of bones, fish-bones, 
buttons, beans, etc., were removed under its guidance, without 
resorting to tracheotomy. Of course, the process must always 
be preceded by skiagraphic localization. The technic of this 




Fig. 122.— Bronchoscopy, after Killian. 



new method is rather difficult and should be practised by an 
expert only (Figs. 122 and 123). 

When the bloodless methods fail inferior tracheotomy 
must be performed without delay. If the foreign body was 
movable the chances are that it is ejected as soon as the 
trachea is opened. 

When the foreign body has become anchored, it must be 



Intrathoracic Tracheotomy. 



243 



loosened by the aid of suitable forceps under the control of 
the bronchoscope, which is to be introduced through the 
tracheal wound (see Fig. 122). 

When it is found that the foreign body cannot be extracted 
by these manipulations, access must be gained by intrathoracic 
tracheotomy or thoracotomy. Intrathoracic tracheotomy is 
performed by exposing the trachea as far down as to the 




Fig. 123. — Instruments for Extracting Foreign Bodies from the Bronchi. 

a, Toothed catcher, b, Blunt catcher, c, Foreign body and catcher in the 
bronchus. 



crossing of the innominate vein. This is best done by ex- 
tending the tracheotomy-wound down to the ensiform process 
and dividing the sternum by a saw in the median line after the 
vein is pushed aside. Then the trachea is seized with a strong 
holding forceps and pulled upward so that the bifurcation is 
made accessible. This procedure is very risky, however, and 
always followed by grave mediastinitis. 

Thoracotomy is far more preferable. After the foreign 



244 Intrathoracic Diseases. 

body is localized by the Rontgen method three rib-portions 
are resected above the area after the exploratory principle 
(see page 188). The further procedures are done according 
to the rules described in the operation for abscess of the lung 
(page 207). If great haste is not required some prefer to pro- 
duce pleural adhesions first by the application of a paste of 
chloride of zinc. For further proceeding into the lung-tissue 
Paquelin's cautery should be given preference. Sometimes the 
foreign body is felt by introducing an aspiratory needle, slight 
manipulations sufficing to dislodge it, so that a cough-attack 
is apt to expectorate it. 

In the case of procrastination it is less the foreign body 
which troubles the surgeon, than its consequences, viz., bron- 
chiectasis, abscess, or gangrene (see page 211). 

Compression of the trachea is often the result of foreign 
bodies in the oesophagus (see above), the direct consequences 
being dyspnoea, which would necessitate tracheotomy as long 
as the efforts of extraction are unsuccessful at the time. 
Septic bronchitis, pneumonia, and pleuritis may be responsible 
for the fatal outcome in an indirect way. Sharp bodies may 
produce perforation of the trachea and haemorrhage from an 
injured vessel. 

Fig. 124 shows the skiagraph of a child of two years who 
swallowed a 5-cent piece six days before. Rontgen examination 
was resorted to, the child not having shown any grave symp- 
toms during the first few days. On the fifth day respiratory dis- 
turbances were noted. When the author saw the child six days 
after the accident he could locate the coin at the level of the first rib. 

Extensive broncho-pneumonia had supervened in the mean- 
while. The frequent respiratory movements made it very 
difficult to obtain a good skiagraph. In spite of the great rest- 
lessness of the patient an exposure of twenty seconds sufficed 
to produce a distinct representation of the coin. The plate 
also shows the ramifications of the bronchi. 

The extraction of the coin was done too late and the child 
succumbed to pneumonia. This is the regular course of such 
cases if their nature is recognized too late. Nowadays there is 
no excuse for such unusual procrastination. 



Extraction of Coins. 



245 




CHAPTER IV. 

THE VALUE OF THE RONTGEN METHOD IN 
THORACIC SURGERY. 

In the diagnosis of the diseases of the chest the screen 
displays its main virtues, since it permits of the observation 
of organs while they are in continuous motion. The number, 
rhythm, and shape of the various motions can be distinctly 
studied. 

The chest may be fluoroscoped while the patient is standing 
or seated on a chair provided with a low back. As a rule, 
soft tubes should be used for thoracic examination, the harder 
variety being preferred for the representation of dense foreign 
bodies only. The dorsal vertebrae, the ribs, the clavicle, their 
injuries, diseases, and malformations (supernumerary ribs), 
can be seen. The heart, the lungs, the pleura, and the dia- 
phragm can be studied thoroughly. Foreign bodies in the tho- 
racic cavity are easily recognized, and most diseases of the 
thoracic cavity, as, for instance, enlargement or displacement 
of the heart and effusion in the pericardium, as well as 
aneurysm and the various kinds of mediastinal tumors, can be 
studied. 

Pneumonic solidification, phthisical foci, cavities, abscesses, 
tumors, bronchiectasis, emphysema, and retractions of the 
lungs can be recognized by fluoroscopy as well as by ski- 
agraphy. Effusions in the pleural cavity, also fibrous swards 
of the pleura and irregularities of the excursions of the dia- 
phragm, are noted. 

For skiagraphing the patient an even table of strong 
construction or the carpeted floor is selected. Posterior 

246 



Thoracic Skiagraphy. 247 

irradiation is done in the dorsal position, the spinal column, 
as well as the posterior portions of the ribs, with their heads, 
necks, and tubercles, becoming apparent, especially at their 
right side. The direction of the posterior ribs is downward, 
while that of the anterior is upward. The image of the anterior 
aspect of the ribs is naturally diffused on account of the much 
greater distance from the plate. Soft tubes show the ribs best, 
the time of exposure not to exceed two minutes, if a Wehnelt 
interrupter is used. 

In skiagraphing anteriorly by posterior irradiation, the 
patient lying on his abdomen, the clavicle, the sternum, and 
the adjoining ribs can be well defined. The distinctness of 
the skiagraph suffers, however, on account of the patient's 
oppressed respiration. In view of the distance it seems natural 
that the spinal column and the posterior ribs appear diffused. 
The heart being situated so near the anterior chest-wall, shows 
a well-marked outline. The shadow of the large blood- 
vessels is less distinct. The shadows of the normal lungs, 
especially the middle portions, are extremely light. 

The upper dorsal vertebrae, as far as they are not obstructed 
by the shadows of the heart and the large vessels, show fairly 
well. The same applies to the three left dorsal vertebrae. 
The other portions of the spinal column appear indistinct 
within their extent of the thorax. Abscesses can sometimes 
be recognized in this region by using the diaphragm. The 
outlines appear more marked in oblique projection, but there 
the skiagraph becomes considerably distorted. 

The sternum is best represented by a short exposure. 
For this purpose a hard tube must be chosen, the patient 
being requested to hold his breath for fifteen to twenty seconds. 
The sterno-clavicular junction shows well. The presence of 
tumors, osseous diseases, capillary gummata, etc., must be 
recognized. For comparison the normal anatomic relations 
of the thorax should always be kept in mind (Fig. 1 25). 



248 Rontgen Method in Thoracic Surgery. 



Mm slenwhijoidet sternothyrcoid 

Trachea, 

61 t/iyreotda 
A carot dext 




■vMBm 



tig teres - 



—\ — Flex coU sin. 

m- -; Stomach 




From Beck's " R6ntgen-Ray Diagnosis," copyright, 1904, by D. Appleton and Company. 

Fig. 125. — Normal Anatomical Relations of Thoracic Organs. 



Physical and Rontgen Method. 249 

In regard to the study of the diseases of the lungs it may 
be maintained that whoever does not master the principles 
of auscultation and percussion is not fit to comprehend the 
fluoroscopic or skiagraphic signs. There are conditions in 
these organs that can be better elicited by the so-called physical 
methods, and others that can be ascertained only by means 
of the Rontgen rays. While the rays show small tumors or 
infiltrated foci which, on account of their central location, can- 
not be diagnosticated by the physical methods, they have the 
disadvantage of always showing the thoracic image in toto — 
that is, they represent all the shadows of the tissue situated 
before as well as behind the diseased area at the same time. 

At the early stage of tuberculosis of the lungs valuable 
information can be derived from irradiation. Williams found 
the diaphragm abnormally high at the affected side in inci- 
pient tuberculosis on fluoroscopic examination. 

Solidification and atelectasis, as well as exudation and 
calcification, can be well demonstrated. The infiltrated walls 
of cavities are recognized as more or less distinct shadows 
surrounding a light area. The true nature of the various 
shadows is often better understood, if, after previous skia- 
graphic representation, the thorax is also fluoroscoped in 
different positions. In that case we see the area, which 
causes bronchial breathing, so to say, instead of auscultating 
it. Fig. in, for instance, represents extensive tuberculous foci 
in the right lung of a woman of thirty-five years. The large 
number of the foci and their partial confluence point to an 
advanced stage. Clinical observation corroborated this as- 
sumption. The sharply outlined obscure foci are of an older 
date, while the light shadows surrounded by foggy contours 
indicate recent destruction. 

Localization of abscess, bronchiectatic cavity, echino- 
coccus, and gangrene of the lungs can always be obtained 
by the Rontgen method. While it may well be appreciated that 



250 Rontgen Method in Thoracic Surgery. 

the uncertainty of the physical method has in former years pro- 
duced a pardonable timidity on the part of the surgeon, nowa- 
days there is no more excuse for such procrastination. 

To study relations the screen offers the best chances, 
as it gives information about the mobility of the diaphragm 
and the degree of expansion. Thus during deep inspiration 
it may be ascertained whether the dark shadow of a focus 
approaches the thoracic wall or is more centrally located, an 
area of normal lung-tissue being between them. 

The size of the foci can be estimated best by stereoscopic 
exposures, while the photographic plate in proportion to the 
different projections gives different sizes. Such points are 
of great importance in all thoracic diseases except in pulmonal 
cavities, which must be approached by the surgical knife. 
There it is the question of localization only which is of 
importance. Consequently the representation of the focus on 
the skiagraphic plate is the leading factor. Even if the shadow 
of the focus is so situated that in the ventral as well as in the 
dorsal position it is overshadowed by the shadow of the heart, 
we are able by oblique irradiation to represent it. The tissue 
defects appear as light areas, with which the surrounding 
cavity walls contrast as dark shadows of an irregular circular 
or elliptic shape. It is evident, therefore, that the focus is not 
representable as such, but that it is recognized by its walls, in 
other words, by the area of pneumonic infiltration around it. 

This infiltrated sphere is less translucent and its outlines 
define the greater or lesser shadow in accordance with the greater 
or lesser degree of infiltration. Of course, if gangrenous frag- 
ments are situated in the cavity as loose sequestra, they also 
cast a dark shadow on the plate, but then they are recognized 
as such inside of the focus. 

The difference of the projection is determined by comparing 
the size of the focus in the ventral as well as in the dorsal position. 
Thus it is recognized whether the focus is nearer the dorsum 



Coin in Pulmonal Cavity. 251 

or the anterior chest- wall. If the shadow shows in the ab- 




From Beck's "Rontgen-Ray Diagnosis, 11 copyright, 1904, by D. Appleton and Company. 

Fig. 126. — Introduction of Foreign Body (Coin) into Pulmonal Pus 
Cavity. 



dominal position as well as it does in the dorsal, it must be 
centrally located. 



252 Rontgen Method in Thoracic Surgery. 

In gangrene the gradual clearing up of the formerly solid- 
ified area can be observed. Similar views apply to echino- 
coccus. 1 

For describing the modus operandi Fig. 120, which illustrates 
the case of a man of thirty-five years who was stabbed in the 
back, may serve. Little reaction following at the time, an in- 
jury of the lungs was not thought of until, three days later, chills, 
haemoptysis, and pleuritic symptoms announced the develop- 
ment of pleuropneumonia. Later a purulent effusion was dis- 
charged by simple thoracotomy. 

The suppuration continuing, resection of a rib was 
performed a few months later. The patient improved then, 
but recovery did not take place. Three years after the injury, 
when the author examined the patient for the first time, 
moderate dyspncea, diminished bronchial breathing, and 
rhonchi were observed. Elastic fibres were also found. The 
injection of liquids into the fistulous tract produced violent 
attacks of coughing. A few minutes after the introduction of 
a strip of iodoform gauze the patient noted a decided taste of 
iodoform in his mouth. 

Fluoroscopic examination showed the whole side, with the 
exception of the upper lobe, slightly veiled and the excursions 
of the diaphragm somewhat restrained. Below the scapula 
the indefinite outlines of a shadow of the size of a silver dollar 
could be perceived. By skiagraphic exposure an irregular focus 
of the same size was recognized on a level with the eighth rib. 
The outlines of the shadow appearing more marked in the dorsal 
than in the ventral position, the focus was supposed to be nearer 
to the dorsum. Therefore the seventh rib was resected first 
below the scapula, access being gained gradually to the pleura 
by the exploratory method. The margins of the pleural canal 
showed themselves considerably hypertrophied in some por- 

1 See " Echinococcus of the Lungs," " Journal of the American Medical Associ- 
ation," November 19, 1898. 



Diaphragm in Hypertrophied Pleurae. 253 

tions, which explained the cloudiness of the skiagram. The 
diameter of some of the swards amounted to an inch. After 
these fibrous areas were removed, access was gained to a pul- 
monary cavity the extent of a hen's egg. The granulations 
which lined it were removed and a loose packing with iodoform 
gauze used. 




Fig. 127. — Strip of Iodoform Gauze in Gangrenous Focus. 

A probe introduced into the cavity showed a depth of 10 
centimetres. The question of localization could be well 
studied in this case by introducing a penny, enveloped in 
gauze, into the cavity and then attaching lead-letters outside 



254 Rontgen Method in Thoracic Surgery. 

of the thorax by adhesive plaster. Thus the point of conver- 
gence of two lines can be constructed. 

The skiagraph taken a week after operation shows penny and 
probe and the various shadow tints — viz., the very light centre 
indicating the abscess cavity and the slightly darker outlines 
of the upper portion of its wall. The lower margin is over- 
shadowed by the fragment of the eighth rib. At a slight dis- 
tance from the abscess wall the dark margins of the remainder 
of the thickened pleura can be recognized. Another skiagraph, 
taken three months afterward, proves the whole sphere con- 
siderably cleared up, this fact harmonizing with the splendid 
condition of the patient. 

In cases of old standing, where the pleurae became thickened, 
and particularly where pyothorax was one of the complications, 
the rib-resection should be most extensive not only in order to 
permit of thorough inspection but also to favor collapse of the 
chest-wall. It is advisable in such cases to remove the peri- 
osteum almost entirely to avoid reformation of osseous tissue, 
which, while desirable under ordinary circumstances, would 
prevent thorough agglutination in this peculiar instance. If a 
portion of the surrounding tissue has undergone such changes 
that its restoration becomes doubtful, it may be compressed by 
an elastic ligature, after being mobilized, and removed a few 
days thereafter. 

The question whether there is only one focus is also deter- 
mined by the skiagram. In order to get more detailed in- 
formation it is necessary, therefore, to use the tubular dia- 
phragm after a general view of the lungs is obtained. That 
area which shows the shadow on the large plate is marked and 
exposed through the diaphragm. By this procedure an ap- 
parently diffuse process proves to be a conglomeration of a few 
gangrenous foci, generally a larger one surrounded by two or 
three smaller ones. Even if the focus is overshadowed by a rib, 
the border of the focus will at least be shown if the diaphragm 



Recognition of Small Foci. 255 

be used. The same applies to the old cases in which the 
thickened pleura veils the foci. 

In previous years the presence of additional foci was assumed 
as soon as after the opening of one focus the symptoms of re- 
tention persisted, while the Rontgen method enables us now to 




A B 

Fig. 128. 
A, Ordinary skiagraph showing thickened pulmonal pleura veiling the abscess (al- 
though the sixth, seventh, and eighth ribs, together with the costal pleura under- 
neath, were removed). B, View of the field of operation immediately after 
interference (moss-board ready for covering the wound). 

recognize their presence at the time of the operation. And 
if the presence of an additional focus was overlooked the 
cavity is made more conspicuous on the skiagraphic plate if it 
is filled with iodoform gauze (see Fig. 127). There the extent 



256 Rontgen Method in Thoracic Surgery. 

of the drained cavity appears in contrast to the area which 
had not been reached. It is self-evident that its relation to the 
accessible cavity also serves as a guide for the direction of our 
further procedures. Repeated skiagraphic examination will 
thus be a reliable control of the further course. 

In regard to the treatment of gangrenous foci it may be 
added, that if a general anaesthetic can be employed at all, 
which naturally facilitates matters, the author prefers ether, 
in spite of its disadvantages. 

In one of the author's delayed cases of pulmonal gangrene 
the condition of the patient became so grave after rib- 
resection that the operation was interrupted before the 
focus could be reached. The patient was resuscitated and 
the cavity opened on the following day. The patient, a man 
of forty years, made a good recovery. 

This modus operandi is recommended in all cases of that 
kind. 

The clinical aspects of that type of gangrene of the lung in 
which the process of necrotic destruction is associated with 
abundant pus-formation are very much like that of pulmonal 
abscess. Since the treatment is practically the same, the differ- 
ence is only of statistical importance. It seems that this com- 
bination-type is the most frequent. Where perforation of a 
focus into the pleural sac took place, the symptoms of pyo- 
thorax prevailed, of course. In such cases a fistula is gener- 
ally found, which serves as a guide to the cavity. 

The author knows of no contraindications in gangrene of 
the lungs because there is no possibility of recovering by any 
other than operative means. As soon as the diagnosis is made, 
the focus should be exposed and drained. 

Pleura. — Pleuritic effusions show a marked opacity 
through the fluoroscope. The larger the amount of effusion, 
the greater the degree of opacity. In pyo thorax the opacity is 
somewhat less complete than in serothorax. 



Rontgen Method in Pleuritic Effusions. 257 

Especially on the right side the outlines of the liver show 
a marked contrast to the lower boundary-line of the effusion. 
The inner boundary-line of the effusion generally appears 
convex, but if the patient inspires deeply, or if he coughs 




Fig. 129. — Small Gangrenous Focus, shown Below the Eighth Rib by the 

Diaphragm. 

Before resection the focus covered by the eighth rib was not recognized on an ordinary 

skiagram, while with the aid of the diaphragm the outlines were indicated. 



violently, it loses its convexity and becomes horizontal. By 
changing the position of the patient, of course displacements 
of the effusions are observed accordingly. Uniform trans- 
parency above the effusion points to the result of a simple 



258 Rontgen Method in Thoracic Surgery. 

inflammatory process, while constant opacities of an irregular 
appearance justify a suspicion of a beginning tuberculosis. 

As a rule, it is found that the area of dullness corresponds 
to the area of shadow. 

Pyothorax. — The diseased tissues in pyothorax show a 
greater density than those of the lungs. The diaphragm 
appears to be depressed. 

The extent of a pyothoracic cavity can be recognized by 
filling it with iodoform glycerin or with a solution of iodide 
of potassium. Water will also produce a shadow. The 
subnitrate of bismuth, which is not permeable by the rays, 
furnishes a still more marked contrast; but as it interferes 
with the treatment, its use cannot be recommended for this 
special purpose. The screen also shows the degree of expan- 
sibility of the compressed lung. The rays prove, furthermore, 
that, after subperiosteal resection of a rib, the exsected portion 
is always more or less reformed (Fig. 100) . 

Hydropneumothorax shows the very dark outlines of 
the exudation in contrast to the light shadow of that intratho- 
racic area which contains air. The dark boundary-lines of the 
exudation can be recognized by the screen as an ascending 
and descending line during the respiratory movements. 

Heart. — The patient may be examined in the sitting as 
well as in the recumbent posture. The tube should be as 
near to the thorax as possible, but it must not be overlooked 
that the size of the shadow of the heart is exaggerated. For 
proper interpretation the distance of the tube must therefore 
be noted, especially if tracing is done for later comparison. 

The importance of recognizing an enlargement of the 
heart is evident. Our physical methods are so highly developed 
that the diagnosis of an enlargement will seldom be difficult 
with their aid. In some instances, however, comparison can 
be made with a higher degree of mathematical exactness 
by the Rontgen method than percussion would permit. So, 



Dextrocardia. 259 

for instance, Schott (Nauheim) could demonstrate by the rays 
that the hearts of bicyclists were temporarily enlarged after 
a great exertion. 

Our knowledge as to the effects of valvular lesions, as to 
fatty degeneration, aneurysm, sclerosis, pericardial adhesions, 
etc., was very much increased by fluoroscopic examination. 

The movements of the heart can be thoroughly studied, 
its regular contractions especially being easily observed. For 
exact measuring, the various stages of respiratory movements 
must be carefully noted, so that no errors occur when com- 
parison is made with later results. The pulsations are most 
marked during the stage of expiration. 

The observations of Williams and Benedikt proved that 
some physiological errors in regard to the mode of contraction of 
the heart existed. That the heart does not empty itself com- 
pletely at each systole becomes evident by the presence of 
a large blood-shadow. Thus we learn that the contractions of 
the heart are not of the extent assumed heretofore. In pro- 
portion to the amount of blood filling the ventricles the 
shadow of the apex appears lighter or darker. 

During deep inspirations it can be observed that the 
diaphragm becomes distant from the heart, which proves 
that the heart is suspended by its blood-vessels and is not 
supported by the diaphragm. Full inspiration shows the 
lungs more translucent, so that their shadow appears in greater 
contrast to the dark outlines of the heart. 

Dextrocardia is easily represented by the Rontgen rays. 
In all these cases it should be ascertained whether there is 
total transposition of the viscera, in which event the appendix 
is also found on the left. (See author's case of left-sided chole- 
cystostomy for left-sided cholelithiasis, " Annals of Surgery, 1 ' 
May, 1899.) 

Pericarditis is sometimes caused by a fractured rib- 
fragment which has pierced the pericardium. 



260 Rontgen Method in Thoracic Surgery. 

A trauma of this kind may be elicited by the Rontgen rays. 
If the clinical symptoms are slight and the rays show no dis- 
placed splinters, expectant treatment is entirely justifiable. 
Even if a bullet, after having fractured a rib, has entered the 
pericardium, there may be no need of surgical interference, 
providing no comminution is shown and severe symptoms are 
absent. 

In a man who was shot, eight years before his death, into 
the supraclavicular fossa from above, the bullet could be 
located at the apex of the heart. The patient had never 
suffered from any symptoms pointing to the presence of the 
bullet. At the autopsy, performed by the author at the St. 
Mark's Hospital, the bullet was found embedded in fibrous 
tissue in the pericardium. 

The evidence of a large bone-splinter pointing toward the 
pericardium is an indication for exposing the pericardial sac 
after the resection of the left fourth, fifth, and sixth ribs. 
These need not be resected in their totality, but may be folded 
up at their sternal junctions like a bone flap of the skull. 

The diagnosis of pericardial adhesions may be verified by the 
fluoroscopic screen, which would show limited expansion. 



CHAPTER V. 
SUBPHRENIC ABSCESS. 

While subphrenic abscess, as its name indicates, is situated 
below the diaphragm, that is, outside of the thoracic cavity 
(Fig. 133), it bears so many relations to the latter that it de- 
serves thorough consideration in connection with the surgical 
disorders of the thorax. It is only since a little over a decade 
that subphrenic abscess was granted a place in medical liter- 
ature. A few isolated cases were reported, before this time, 
Leyden, Tillmann, and Sachs in Germany, Penrose and 
Mackenzie in England, and R. F. Weir, 1 S. J. Meltzer, and 
the author 3 publishing cases in this country. 

Notwithstanding that surgery owes most of its recent 
development to advances in the natural sciences, yet here 
surgery has been the donor by disclosing to pathology as well 
as to internal medicine the mysteries of this disease. 

It was reserved to the genius of a Richard von Volkmann 4 
to show, as early as 1879, that abscesses situated below the 
diaphragm can be reached and cured by the knife. His bold 
yet successful procedure of opening the pleural cavity and 
incising the diaphragm called the interest of the whole medical 
world to this new subject. 

In the .following year Leyden 5 published his views upon 
this condition from the standpoint of general medicine, and 
to him is due the credit of having offered the first clear and 

1 "Medical Record," February 13, 1892. 

2 "Internationale klinische Rundschau," 1893, Nos. 29, 31, 34. 

3 'Medical Record," February 15, 1896. 

4 "VerhandlungenderDeutschen Gesellschaft fur Chirurgie," Bd. viii, 1879, p. 19. 
5 " Zeitschrift fur klinische Medicin," Bd. i, p. 320. 

261 



262 Subphrenic Abscess. 

simple methods for its diagnosis. How much the knowledge 
of this subject has increased is evident from the fact that, while 
from 1879 to 1890 only twenty-eight operations were per- 
formed for subphrenic abscesses, the period from 1890 to 1893 
shows thirty- two cases. The record has since risen to more 
than one thousand cases, most of which were operated upon. 
Notwithstanding our advanced knowledge there are still num- 
erous aetiological and diagnostic points which await elucidation. 

This is the more to be deplored that here, as in many 
other suppurative processes, early diagnosis is essential to 
successful surgical treatment. Even the most experienced 
observers sometimes meet with great difficulties in diagnosis, 
which can be overcome only by clearing up the manifold 
aetiological factors. The first classical efforts in this direction 
were made by K. Maydl. 1 

Subphrenic abscesses are classified best in conjunction 
with their anatomical points of origin. At the same time the 
primary disease which caused the abscess must be studied 
whenever possible. Since diagnosis and prognosis, as well as 
therapy, are naturally dependent upon the seat of the primary 
affection, anatomy has served also as the basis for the author's 
own deductions. Before going further, the topography and 
pathological anatomy of the disease as the basis for diagnosis, 
prognosis, and therapy will be considered. 

Topography. — The subphrenic space, in which sub- 
phrenic abscess forms, is bounded by the epigastrium and 
the two hypochondria. The right hypochondrium contains 
the right lobe of the liver, the sharp lower margin of which is 
overlapped by the gall-bladder in the region of the, cartilages 
of the ninth and tenth ribs. Below the liver is the right half 
of the transverse colon. The right suprarenal capsule and the 
upper margin of the right kidney, which always leaves a 

1 " Ueber subphrenische Abscesse," Wien, 1894. 



Topography of Subphrenic Abscess. 263 

slight impression upon the liver, occupy the most dependent 
part of the right hypochondrium (Fig. 130). 

The left hypochondrium, containing the fundus ventriculi, 
is covered by the larger portion of the left lobe of the liver. A 
little further below lies the spleen, connected with the curva- 



Z.Tib 




Fig. 



osi?. 



130. — Vertical Section through the Human Body, One Inch to the 
Right oe the External Margin of the Left Rectus Abdominis. 



ture of the stomach by the ligamentum gastro-lienale and the 
vasa breviora. In front of the spleen lies the left part of the 
transverse colon. That part of the epigastrium adjacent to 
the anterior abdominal wall contains a part of the left lobe of 



264 Subphrenic Abscess. 

the liver, separated from the wall of the abdomen by the sus- 
pensory ligament. The pylorus and a portion of the duode- 
num are below the liver. 

About on a level with the lower margin of the nipple (lower 
margin of ninth to eleventh dorsal vertebrae posteriorly), the 
diaphragm forms a figure-of-eight, whose knot is situated 
between the oesophagus and the pericardium. The peritoneal 
coat of these organs is incomplete at three portions: (1) at the 
suspensory ligament of the liver; (2) where the lobus Spigelii 
touches the minor omental bursa, at the lower surface of the 
liver; and (3) at the portion situated between the end of the 
bursa omenti and the posterior end of the peritoneal cavity, 
which adapts itself to the liver from in front. 

Fig. 130 shows the upper half of the anterior surface of the 
left kidney covered by peritoneum, while the lower half is not 
covered by serosa. It is separated behind the stomach from 
the great omental bursa by the suprarenal capsule and the 
pancreas. The anterior surface of the stomach has a serous 
coat which faces the great peritoneal cavity, while its posterior 
serous coat forms the anterior wall of the great omental bursa. 
The posterior portion of the same covers the anterior surface 
of the pancreas and the end of the duodenum. The serous coat 
of the stomach running downward covers the transverse colon. 
The upper portion of the transverse mesocolon passes over to 
the pancreas, thereby forming the posterior wall of the great 
omental bursa, while the lower portion passes over into the 
mesentery of the small intestine. 

These anatomical facts show that, with the exception of 
the cardiac region and the junction of the great and small 
omental bursa, the stomach does not anywhere adapt itself 
directly to the subphrenium, but touches it with a serous coat 
which comes from another organ. Consequently the stomach 
may be the medium of intraperitoneal as well as of extraperi- 
toneal subphrenic abscess. 



Extraperitoneal Abscess. 



265 



Extraperitoneal abscess could also originate from the left 
lobe of the liver, if it perforate alongside the triangular ligament 
into the subphrenic space. 

On the right side (see Figs. 131 and 132), the whole dia- 




Aep.fl.col. 



Fig. 131.— Vertical Section through the Right Rectus Abdominis. 



phragmatic garret is filled by the right lobe of the liver. Pos- 
teriorly the right kidney slightly indents the liver, touching the 
diaphragm with the upper half of its posterior surface and the 
psoas muscle with the lower half. The liver is covered with 



266 



Subphrenic Abscess. 



peritoneum from its lower margin up to trie hilus. The pos- 
terior surface of its convexity, as well as its posterior margin 
the posterior half of its lower surface, are not covered with and 
peritoneum toward the median line, but have a peritoneal coat 



/ 



/ 




Fig. 132. — Anatomical Relations of the Right Thoracic Half. 



laterally. Only the upper surface adapts itself to the dia- 
phragm directly. 

In front of the lower surface of the kidney is the duodenum, 
partly covered by the serosa of the small omental bursa. In 
front of it projects the pyloric portion of the stomach, whose 



Pathology of Subphrenic Abscess. 267 

anterior surface is coated with the serosa of the lower anterior 
surface of the liver. The transverse colon is often found in front 
of the pylorus, while neither the transverse nor the ascending 
colon has ever been found between the convexity of the liver 
and the anterior abdominal wall, as the external convexity of 
the liver always lies close to the abdominal wall. 

The peritoneal coat of the liver sometimes embraces the 
gall-bladder completely, forming a mesentery for it, from 
which it hangs ; sometimes it merely passes over its lower sur- 
face and binds it closely to the lower surface of the liver. The 
pancreas is separated from the posterior surface of the stomach 
by the great and small omental bursae, and lies very close to 
the diaphragm. 

Pathological Anatomy. — From a pathological point of 
view subphrenic abscess (synonyms: hypophrenic abscess, 
subdiaphragmatic abscess, subphrenic empyema, empyema 
hypophrenicum, pyopneumothorax subphrenicus, perigastric 
abscess, perigastritis, false pneumothorax, localized tympanites, 
suppurative perihepatitis, suprahepatic abscess, pneumoper- 
forative peritonitis, subperitonitis) is divided into intraperitoneal 
and extraperitoneal. 

In the first variety the abscess lies wholly within the peri- 
toneal cavity. In the second variety the abscess wall may or 
may not be formed in part by peritoneum, but in any case 
only by its external surface. An important differential point 
in these conditions is that, since an extraperitoneal abscess 
never detaches the peritoneal serosa of the diaphragm from it, 
it is perforce confined within narrow limits and consequently 
does not fill the subphrenium so completely as does one of the 
intraperitoneal variety. Another characteristic feature of the 
extraperitoneal form is that it has a greater tendency to per- 
forate into the thorax, especially into the pleural sac. 

Intraperitoneal subphrenic abscess assumes an entirely 
different significance according to whether it is located on the 



268 Subphrenic Abscess. 

right or the left side of the falciform ligament. This ligament 
forms the median line between the right and left subphrenium. 
As the whole right subphrenic space is filled by the liver, the 
lower wall of an abscess situated on the right side is formed 
by the upper convexity of the liver; while on the left side the 
stomach, as well as the spleen, the transverse colon, and the 
left lobe of the liver, may form a wall. 

Extraperitoneal abscesses are most frequently found on the 
right side. This is quite natural, since clinical as well as 
post-mortem observation has very often traced their source to 
the caecal region. Rarely this form of abscess arises from the 
kidneys or ribs. 

Diagnosis. — As mentioned, subphrenic abscess has a 
proteus-like physiognomy. The beginning of its formation is 
sometimes announced by a chill. Frequently there is intense 
pain at the starting-point of the disease. The fever is of a 
most irregular type, sometimes there is no temperature at all. 
Nutrition is always greatly disturbed and emaciation always 
present. Local tenderness and resistance often point to the 
seat of the abscess. Regarding differential diagnosis, three 
cardinal questions frequently arise, namely: Is the condition one 
of pyothorax, subphrenic abscess, or subphrenic pyopneumo- 
thorax? The pathognomonic essentials of these different 
conditions, as first advanced by Leyden, almost invariably 
remain authoritative. In subphrenic pyopneumothorax deep 
percussion above the retracted lung yields resonance. From 
the third rib downward it is generally full and tympanitic. 
Instead of the liver dullness on the right thoracic margin, a 
profound and full sound is present. Below the right costal 
arch the liver is pushed far into the abdomen, and its lower 
border is easily recognized by palpation and percussion. 

Auscultation shows the absence of respiratory murmur 
from the third rib downward. Amphoric breathing and metal- 
lic tinkling take its place. In auscultatory percussion, metallic 



Diagnosis of Subphrenic Abscess. 269 

phenomena are noticed. There is no vocal fremitus on the 
lower part of the right thorax. The succussion sound can be 
heard by shaking the patient. If the effusion can be made 
out by percussion on the lower thoracic portion, it is found to 
change its seat easily and quickly, whenever the patient is 
turned. If the effusion is situated on the right side, the heart 
will be slightly displaced toward the left, and vice versa. 

It must be remembered, furthermore, that an admixture 
of gas is a characteristic feature of subphrenic pneumothorax 
(Fig. 135). Gas is the product of putrid decomposition, and 
seems to give the pus a capacity for rapidly eroding the sur- 
rounding tissue. An exploratory puncture reveals ichorous pus 
of offensive odor. It is superfluous to say that when the ad- 
mixture of gas is recognized by an exploratory puncture, a 
most valuable point for differential diagnosis is obtained. 

The history is often an important guide as to the location 
of the abscess. It is characteristic for subphrenic abscess that 
there is often a history of previous abdominal disturbance, 
while cough and expectoration are absent. The heart is little, 
if at all, displaced, and there is no ectasy of the thorax or of 
the intercostal spaces. In the lungs, vesicular breathing is 
found below the clavicle. Pectoral fremitus is also clearly 
perceptible. There is a well-marked limit to the region of 
vesicular breathing, below which the expiratory murmur is 
replaced by amphoric sounds. Deep inspiration pushes the 
boundary-line of the region of vesicular breathing much 
farther down, into areas in which formerly no respiratory 
murmur could be perceived. This would indicate a well- 
marked separation between the lungs and the abscess cavity, 
the boundary-line of the lungs protruding toward the abscess 
cavity during deep inspiration. 

It is sometimes impossible to distinguish an encysted 
pleuritic effusion from a subphrenic abscess. The pathog- 
nomonic signs of such pleuritic effusions emphasized by Leyden 



270 



Subphrenic Abscess. 



were absence of cough and expectoration, slight displacement 
of heart, and rapid change of note if the patient is rapidly 
turned. But, according to the author's observations, 1 pleuritic 
effusion, particularly pyothorax, sometimes occurs without 
these symptoms. 

In reference to the absence of thoracic ectasy and the 
inversion of the intercostal spaces as pathognomonic^ sub- 
phrenic pyopneumothorax, it must be said that Herrlich 




From Beck's " Rontgen-Ray Diagnosis." 
Copyright, 1904, by D. Appleton and Company. 

Fig. 133. — Subphrenic Abscess. 
a, Abscess; d, diaphragm. 

holds the opposite view, and claims that ectasy of the lower 
thoracic sphere is rather characteristic of the presence of 
this condition (Fig. 134). 

The motions of the exploratory needle, introduced into the 
abscess, were also regarded as pathognomonic by Fuer- 
bringer. But, bearing in mind that in subphrenic abscess 
the function of the diaphragm is greatly impaired, and that, 
furthermore, the point of the exploratory needle may be fixed 

1 "Pyothorax and its Treatment," "Medical Record," May 19, 1894. 



Diaphragmatic Excursions. 



271 



by the diaphragm as well as by the abscess membrane, neither 
the presence nor the absence of the motions can be regarded 
as determining factors of a pathognomonic nature. 




Fig. 134. — Left-sided Pyopneumothorax. 




Fig. 135. — Left-sided Subphrenic Abscess (Containing Gas). 



If the diaphragm, being pushed up high, tightly adheres to 
the thoracic walls, the needle may invade the subphrenic 
abscess without being fixed by the diaphragm. Consequently, 



272 Subphrenic Abscess. 

even if the diaphragm should still be able to make respiratory 
movements, the needle would not necessarily be moved by 
them. 

The value of Litten's diaphragm-phenomenon is not yet 
established. Jendrassik asserts his ability to note a well- 
marked concave undulating curve parallel to the costal margins 
in the mammary as well as the axillary line during deep inspira- 
tion. In one of his cases he based the diagnosis of subphrenic 
abscess upon this phenomenon. The correctness thereof was 
demonstrated by subsequent operation. 

All these points go to show that, aside from the history, 
there are but few absolutely reliable pathognomonic data for 
the diagnosis of subphrenic abscess. Practically, however, 
it will make little difference to the surgeon whether pyothorax 
or subphrenic abscess is present, as the essential part of the 
treatment of either condition is free opening. The main 
question will always be: Is there an abscess or not? When- 
ever suspicion exists, the introduction of the exploratory needle 
is a matter of course. The same aseptic precautions should 
be observed as in any other operation. The skin of the patient, 
as well as the hands of the surgeon, should be rendered clean, 
and the syringe and needle thoroughly sterile. If the first 
attempt be negative, the needle should be introduced several 
times into different portions, as the pus cavity may either 
be of small extent, or may contain a cheesy accumulation, or, 
finally, may be divided into several minor cavities by adhesions. 

In the first event the cavity may be missed altogether by 
the exploratory needle, and in the second the needle, being 
introduced into the solid cheesy mass, can draw no pus. After 
each negative result, therefore, a wire should be pushed through 
the needle (which must not be of too small a calibre). Thus 
some pus, which had remained adherent to the inner surface 
of the needle, will become attached to the wire. Occasionally 
it will be useful to fill the syringe with sterile water after the 



Prognosis of Subphrenic Abscess. 273 

operation, and force the water through the needle into a Petri 
dish. In case cheesy masses are present,, small particles are 
sometimes drawn into the calibre of the needle which cannot 
be perceived by the unaided eye; but which, by being mixed 
with the sterile water, can be recognized under the microscope. 
In case the microscope does not give sufficient information, 
resort should be had to cultures of the fluid. (Compare aspira- 
tion in pyothorax, page 147.) 

The Rontgen method also made its powerful influence felt in 
the differential diagnosis of subphrenic abscess. It is, in fact, 
greatly simplified now by fluoroscopy as well as by skiagraphy, 
the space between the diaphragm and the lower boundary-lines 
of the abscess showing distinctly. If the patient is seated on a 
chair, the screen being held in front of the thorax and the 
Rontgen tube behind him, the upper portion of the diseased 
side must appear normal — that is, light. Below this area a 
dark one appears which indicates the diaphragm (Fig. 135). 
Below the diaphragm a very dark shadow is found in case of the 
presence of a fluid. This would correspond to the area of 
the abscess. 

When the patient's position is changed the dark area, in- 
dicating the fluid, also changes. If there is an accumu- 
lation of gas in the subphrenic abscess, a light area will 
be seen above the dark shadow. As soon as the patient is 
shaken, the horizontal line, indicating the border-line between 
gas and fluid, becomes wavy. 

In the recumbent position only the dark area is shown, even 
if gas be present. 

Prognosis. — Experience shows that the prognosis of sub- 
phrenic abscesses, except those of malignant origin, such as 
carcinoma pylori, for instance, depends almost entirely upon 
early diagnosis. The author did not lose any of his simple 
cases which were operated upon early. In none of them, how- 
ever, were there any complications or large sized abscesses. 



274 Subphrenic Abscess. 

In the great majority of the author's cases the ^etiological 
source could be found in the appendix. They were ten in 
number, seven of them recovering. The cured patients were 
all operated upon at an early stage. 

Next to it the aetiological moments could be traced to the 
sphere of the liver and gall-bladder. They figure with six 
cases, four of them recovering. 

In their totality the author's statistics from January 3, 
1892, are as follows: 

/Etiological Source. Number of Cases. Recoveries. 

Appendix 10 7 

Liver and gall-bladder 6 4 

Pyothorax 6 4 

Stomach 4 2 

Costal necrosis 3 3 

Perinephritis 3 2 

Spleen 3 2 

Duodenum 2 1 

Pancreas 1 o 

Unknown sources 6 4 

44 29 

This means 15 deaths among 44 cases; in other words, a 
mortality rate of 34.1 per cent. The mortality rate of 50 
per cent., as given by Maydl, seems to be too high. Con- 
sidering that Scheurlen's mortality rate was 82.5 per cent., 
while Sachs, in a series of six cases, lost none, it can clearly 
be seen that the kinds of cases reported differ notably. Further- 
more, it must be borne in mind that very few of the cases reported 
in the unfortunate series of Scheurlen were operated upon. 
Thus it becomes evident that an approximate judgment can be 
based only on a large number of well-defined cases. 

Spontaneous healing of subphrenic abscess is extremely 
rare, as is that of pyothorax. Perforation may take place 
into a hollow organ, like the stomach, or a bronchus, or the 
bladder. Literature shows spontaneous cures of subphrenic 
abscess six times in one hundred and four cases. As the 
mechanism of such natural healing is unknown to us, and there- 



Bacteria in Subphrenic Abscess. 275 

fore cannot be controlled by any medical therapy, it can only 
be by chance that so hazardous a cure is ever effected. 

Since the pathology of appendicitis has been more widely 
recognized, poulticing and opium have ceased to be the pan- 
aceas, early opening being demanded now. The same views 
apply to subphrenic abscess. Its expectant treatment will be 
discarded as soon as its importance and nature are better 
recognized. 

Microscopic and bacteriological examination of the aspirated 
pus gave no prognostic aid in the author's cases. But it may 
fairly be assumed that with greater interest in this disease and 
the higher development of our examining methods, more 
valuable information on these points will be obtained. It is to 
be regretted that, according to the reports of reliable investi- 
gators, most of the pus-culture experiments made so far were 
negative. Probably the microbes are dead, since even the 
pus taken from the subphrenic abscess of tuberculous patients 
has repeatedly failed to produce reaction when injected into 
rabbits. 

Thus far the pus of these abscesses has been found to 
contain the staphylococcus pyogenes aureus, streptococcus, 
bacillus coli communis, bacillus pyogenes fcetidus (Passet), 
micrococcus tetragonus, various species of proteus (Hauser), 
saccharomyces, and diplococcus citreus conglomeratus. As the 
analogy with pyothorax is obvious, it may be remembered that 
the pus of that condition shows streptococcus, bacillus tubercu- 
losis, typhus bacillus, staphylococcus aureus and albus, and 
diplococcus lanceolatus (Frankel). As mentioned above, 
Netter in 109 cases of pyothorax found streptococcus 50 times, 
pneumococcus 32 times, saprogenous micro-organisms 15 
times, Koch's bacillus 12 times. The presence of pneumo- 
coccus in subphrenic abscess would suggest a pulmonic origin. 
We know that the presence of streptococcus in pyothorax seems 
to favor the formation of solid masses in the effusion, and, 



276 Subphrenic Abscess. 

furthermore, that this coccus has a predilection for the infec- 
tious diseases of adults, whereas FrankePs coccus shows the 
most benign character of all microbes found in pyothorax. 
Whether this is accidental or not, and how much the analogy 
can be utilized for the prognosis of subphrenic abscess, the 
future must show. 

Undoubtedly the prognosis is also influenced by the extent 
of the accumulation, the consistency, appearance, and odor 
of the pus, the age and the constitution of the patient, the pulse, 
the temperature, and, perhaps the most important of all, the 
stage of the disease. If the percentage of successful operations, 
as reported in literature, is still far from being satisfactory, it 
can be due only to disregard for the principle of early operation 
and to the fact that the unsuccessful cases are the result of a 
defect in diagnosis quite as much as in operative technics. 

In all these cases the autopsy showed the presence of 
another abscess, so that the essential condition for success, a 
thorough evacuation, was not fulfilled. In six cases, besides 
subphrenic abscess, pyothorax was present. In nine cases 
abscesses were present in adjacent organs, i. e., in the spleen, 
liver, kidney, etc. In four cases the additional disease was 
suppurative peritonitis. In ten cases there was pneumonia, 
in addition to pyaemia, tuberculosis, actinomycosis of vertebrae, 
etc. In several cases an incision was made, but the abscess 
was not detected during life. 

Varieties classified according to source : By far the greater 
number of subphrenic abscesses are the result of pathological 
processes in the appendix. In view of its situation this fre- 
quency is a natural outcome. Especially in procrastinated 
cases, where isolated abscesses form between adherent loops of 
the intestine, the foundation is laid for further infectious pro- 
cesses. The custom of leaving a gangrenous appendix in the 
abdominal cavity when the appendicular abscess is walled off, 
is also to be held responsible. This policy, tempting as it 



Intestinal Origin of Subphrenic Abscess. 277 

appears on superficial contemplation, is entirely unsurgical and 
cannot be condemned too strongly. Whenever gangrenous tis- 
sue can be reached it should be seized under any circum- 
stances and eliminated. 

Regarding the intestine, it is to be considered that it is no- 
where attached to the diaphragm. Consequently other con- 
ditions prevail here than in those organs which are in direct 
contact with the diaphragm. The experiments of Sanger 
clearly illustrate the manner in which a subphrenic abscess may 
arise from the intestine. This author noticed that when 
he injected a solution of Berlin blue into the retroce- 
cal tissue, only a trifling amount of the colored solution 
could be driven around the caecum and alongside the linea in- 
nominata down to the inguinal canal. But the liquid column 
rose behind the ascending colon, formed a considerable fluid 
collection around the right kidney, and, passing the inferior 
horizontal portion of the duodenum, reached the dull margin 
of the liver and the diaphragm. Little fluid reached the 
transverse mesocolon, and none at all the mesentery of the small 
intestine. From this experiment the rule may be deduced that 
subphrenic abscess is more apt to arise from perforation of the 
caecum, ascending colon, or duodenum, than of the small in- 
testine or transverse colon. The experience gained from 
autopsies is in entire accord with this theoretical assumption, as 
in thirteen intestinal cases, reported by Maydl, perforation of the 
duodenum was found eight times; of the colon, four times; 
while perforation of the ileum was found only once, and that, 
too, near the colon. It is of interest to notice that the aetiological 
factors of these perforations of the gut, with the exception of one 
case which was caused by a foreign body, were all ulcerative pro- 
cesses. Traumatism could never be made out as a primary 
source. The ulcers of typhoid fever, since their favorite seat is 
the small intestine, cannot, according to Sanger's experiments, 
enter into the formation of subphrenic abscesses. Autopsies 



27^ ■[ Subphrenic Abscess. 

have shown that appendicitis causes subphrenic abscess by 
perforation from the appendix into the retroperitoneal space, 
the resulting abscess extending up behind the kidney and 
liver to the subphrenium. From the anatomical situation of 
the appendix, such abscesses are generally found on the right 
side, but in a few cases they passed from behind the right 
kidney, over the vertebrae, to the left kidney. 

Frequent seats of subphrenic abscess are the stomach and 
upper part of the duodenum. There may be direct perforation 
into the subphrenium, due to a peptic ulcer or a neoplasm 
(carcinoma), or infection may occur through the lymphatics 
which drain that part of the stomach involved in the path- 
ological process. Most of the cases reported, however, point 
to simple ulcerative processes as setiological factors. 

As mentioned above, cases of echinococcus are seldom seen in 
this country, but in Germany, Austria, France, and England, 
where it is more common, it frequently figures as a cause of 
subphrenic abscess. Of the subphrenic abscesses due to this 
cause, seventeen were operated upon, as far as literature shows, 
with the result of seven deaths. No case recovered after per- 
foration of the abscess into the pleura, except those treated by 
operative means. 

The starting-point is generally an echinococcus cyst, 
formed in the cellular tissue between the diaphragm and the 
liver. A cyst of this kind may, however, be developed between 
the diaphragm and the left kidney or the spleen, since both 
these organs are occasionally the seat of the parasite, and are 
both in contact with the diaphragm. Simon-Brown, Mosler, 
and Fiaux have reported abscesses from this source. 

In what manner subcutaneous trauma give rise to the forma- 
tion of subphrenic abscess is not always evident. The 
explanation may be that trauma originally causes a simple 
extravasation, into which pus-producing organisms emigrate 
from the neighboring intestine. These microbes are usually 



Biliary Origin of Subphrenic Abscess. 279 

abundantly present in the gut and are found in tissues whose 
vitality has been lowered by trauma, which means a most favor- 
able soil for their further development. 

It is also conceivable that trauma producing a capillary 
separation in the continuity of kidney, pancreas, or liver, causes 
oozing of the secretions of these organs, which may then irritate 
and infect the adjacent tissue. Or a more extensive rupture 
of one of these organs may cause the formation of an abscess 
within it, which might burst into the subphrenic space later. 

Sometimes trauma may be produced by an apparently 
insignificant amount of force. Simply lifting a heavy weight, 
for instance, is reported to have caused it. Literature has 
seventeen cases showing this aetiology, six of them recovering 
after operation and two spontaneously. 

The gall-bladder and the intrahepatic and extrahepatic 
bile-ducts naturally offer marked opportunities for the for- 
mation of subphrenic abscess. Bearing in mind that the 
anterior surface of the gall-bladder adapts itself to the right 
inferior insertions of the diaphragm, it seems obvious that in- 
flammatory processes of this organ extend by means of the 
lymphatics, or by ulcerative perforation to the lower surface of 
diaphragm. Stagnation in the flow of bile undoubtably favors 
the infection of the gall-passages from the intestine. (See 
"Cholelithiasis," "New York Medical Journal," September 8, 
1906.) Retention cysts containing bile may originate in the liver 
itself as well as on its surface, and may burst and discharge 
into the subphrenium. Thus subphrenic abscess may arise 
from purulent cholecystitis terminating in ulceration and perfo- 
ration, or from cholangiectasia due to obliteration of a large 
bile-duct, or from cholangioitis terminating in purulent hepati- 
tis, or from purulent inflammation of the ductus choledochus 
communis itself, followed by rupture. 

There are reports of sixteen cases of cholangioitic origin 
(the author's excepted). Of these, fourteen were not recognized 



280 Subphrenic Abscess. 

until the autopsy, while two were operated upon successfully. 
In several of the cases gall-stones were found. In all of 
them, naturally, the subphrenic abscess was located on the 
right side. Every one of the patients had complained of well- 
defined acute pain in the right hypochondrium. 

The anatomical situation of the kidneys gives them an 
important relation to the formation of subphrenic abscess. 
They are situated in the lumbar region of the abdominal cavity, 
and are covered by peritoneum in front. The right kidney lies in 
contact with the ascending, the left one with the descending colon. 
They are bounded behind by the lumbar portion of the dia- 
phragm, and above by the suprarenal capsules. The left kid- 
ney extends a little higher into the pleural domain, so to speak, 
than the right, so that in perforation from the renal sphere into 
the pleura, the left side is more frequently concerned than the right. 

The most frequent cause of perinephritic abscess is a 
primary perinephritis, arising from a contusion in the renal 
region or from one of the infectious diseases. Another cause 
may be pyelonephritis calculosa, suppurativa, or tuberculosa. 
As to repeated exposure to cold as an aetiological element, see 
page 142, on pyothorax. 

Since suppurative pyelonephritis is often the outcome 
of disease of the uropoietic apparatus, viz., prostatitis, stone, 
carcinoma of the bladder, etc., it will be wise to consider the 
possibility of the formation of a subphrenic abscess in all such 
conditions. 

The lower border of perinephritic subphrenic abscess 
is generally formed by the ascending or descending colon, some- 
times by the duodenum. 

In reference to diagnosis, it is maintained that if the abscess 
occupies the whole anterior or posterior surface of the kidney, 
there is generally tenderness or pain, swelling, and oedema 
on the anterior surface of the abdomen. The author's expe- 
rience, however, does not accord with this, as, with the excep- 



Thoracic Origin of Subphrenic Abscess. 281 

tion of pain, he found no local symptom in one of his own 
cases even as late as seven weeks after the onset of the 
disease. 

If the abscess has formed on the upper surface of the 
kidneys, pleuritic symptoms, combined with oedema of both 
legs, jaundice, ascites, and vomiting, may be observed. Of 
eleven such cases reported in literature, only one was saved, 
the unfavorable course probably being due to delayed diagnosis. 

Perhaps, too, the kidney is so much affected in this 
condition that nephrectomy should be added to the operation 
for evacuation of the abscess. 

Subphrenic abscess originating in the ribs (from a tuber- 
culous osteomyelitis, caries, etc., as a rule) was considered to be 
of rare occurrence. If situated on the right side it may easily be 
confounded with cholangioitic subphrenic abscess. In the 
cases reported in literature, the tuberculous process was local- 
ized, and consequently there was quick recovery. 

But with our advanced knowledge this source is very 
much more frequently detected as such. Fig. 136 shows 
one of the cases of the author in which the diagnosis empyema 
of the gall-bladder due to cholelithiasis was made. The 
patient, a man of thirty-eight years, suffered from costal 
osteomyelitis, perforation having taken place into the sub- 
phrenicum. 

The great tendency of subphrenic abscess to perforate 
into the thoracic cavity has been mentioned before. On the 
other hand, there are subphrenic abscesses of true thoracic 
origin. The most frequent purulent affections of the thoracic 
cavity are pyothorax and abscess 0} the lung. Suppurative 
pericarditis is rare. A circumscribed pyothorax may per- 
forate directly, while abscess of the lung will first produce an 
inflammatory adhesion of the adjacent visceral and diaphrag- 
matic pleurae. Free pyothorax has a tendency to perforate 
the middle of the diaphragm. 



282 



Subphrenic Abscess. 



Of nine cases reported in literature, one case recovered 
spontaneously by perforating into the gut; one after surgical 




Fig. 136. — Anterior Incision Line in Subphrenic Abscess Due to Costal 
Osteomyelitis. (Six Weeks after Operation.) 




Fig. 137. — Dull Area as it is Generally Found in Cases of Subphrenic 
Abscess of the Type Illustrated by Fig. 136, before Operation. 

operation ; three died with, and four without, surgical interfer- 
ence. - 



Traumatic Origin of Subphrenic Abscess. 283 

Metastasis is another important aetiological factor, but is, 
as a rule, observed only in the tropics. It has been found 
after trauma in connection with pyaemia (septic phlegmon 
of the forearm and tuberculous coxitis — Godlee); following 
ulcerative processes in the digestive tract (perforation of 
fish-bone into the vena portae) ; and associated with fistula ani 
and gangrene of the appendix. Abscess of the spleen, per- 
forating into the portal branches, as well as suppurative proc- 
esses in the mesentery and mesenteric glands, may cause 
abscess of the liver. Malaria, enteritis, and dysentery may 
do the same. In tropical dysentery Koch 1 could always 
prove the presence of amcebae in portions of the intestine, and 
regarded them as the aetiological factor. Abscesses of the liver 
were also demonstrated by von Bergmann. Other authors 
claim that the amcebae are not the cause of the abscess, but 
only the characteristic admixture of the secretion transported 
from the seat of ulceration to the liver. 

An attempt was made to obtain cultures from the pus of 
thirteen' cases of dysenteric abscess of the liver. In eight cases 
the results were negative. Among the positive results staphy- 
lococcus pyogenes aureus was found twice; staphylococcus 
albus, bacillus pyogenes foetidus and proteus, once each. 
But in sections and cover-glass preparations amcebae were 
found in every one of twenty-two cases. In ten cases they 
were mixed with bacilli. Of eleven cases reported in literature, 
ten died. In one case recovery was obtained by surgical 
interference. Only two of the fatal cases were operated upon. 

A wound inflicted directly to the diaphragmatic space 
may also in rare instances cause subphrenic abscess, some- 
what as do the subcutaneous traumata described above. The 
wound is generally produced by a bullet. There are in the 
literature reports of autopsies in four cases. The liver, kidneys, 
and thoracic cavity may be involved at the same time. 

1 Gaffky: "Reports on Investigations of Cholera," 18S3. 



284 Subphrenic Abscess. 

Besides' the varieties described above, another group of 
subphrenic abscesses must be mentioned, whose original 
sources either are questionable or cannot be discovered. 
Eleven such cases are reported in literature besides the author's. 
In three of them successful operations were performed. One 
recovered after perforation into a bronchus. The other 
seven died under expectant treatment. In one case actinomy- 
cosis of the vertebrae was found, while there was pyosalpinx 
in the case which finally perforated into a bronchus. 

In those cases of subphrenic abscess originating in diseases 
of the female sexual organs, e. g., endometritis, pyosalpinx, 
perimetritic exudations, the route to the subphrenium is 
through the retroperitoneal space. 

Course. — As said above, subphrenic abscess may arise 
from infection carried from an area of suppuration by means 
of the lymphatics. It oftener originates in an abscess of an 
adjacent organ, which bursts into the subphrenium. The 
fistulous tract representing its route may then become oblit- 
erated, or may remain and gradually grow larger. 

If perforation of a subphrenic abscess into the lung has taken 
place, the rusty sputa and their offensive odor, as well as that 
of the breath, together with the microscopic demonstration of 
elastic fibres, point to a limited gangrenous process as the 
initiative factor of the perforation. 

The cough, which then is always present, generally brings 
up fetid pus, in which particles of food, such as starch grains 
or margarin crystals, can be seen by the naked eye or demon- 
strated by the microscope. This would, of course, point to a 
gastro-intestinal or cholangioitic source. 

While in a small number of such cases recovery is obtained 
by the perforation, the majority of patients succumb either to 
the shock of the perforation itself, or to a foreign-body pneu- 
monia later on. The symptoms of perforation into the pleura 
consist in intense pain, rapidly developing dyspnoea, and 



The Treatment of Subphrenic Abscess. 285 

collapse (see page 84); while those of perforation into the 
peritoneal cavity are identical with the well-known symptoms 
of the general type of peritoneal perforation. 

Therapy. — The treatment of subphrenic abscess must be 
surgical. Before the days of asepsis, the surgeon naturally 
hesitated to open the chest or abdomen, but now such fear 
need no longer prevent him from procuring timely exposure. 
Thorough evacuation can be effected only by wide opening. 
This is secured best by resecting a piece of a rib, as the 
subphrenic abscess is generally within the extent of the ribs. 
Exceptionally it is to be approached below the costal arches 
or the xiphoid process. The 
author cannot agree with those 
authors who pronounce it an ill 
occurrence for the patient when 
the abscess must be reached by 
the transpleural route. On the 
contrary, it seems that no other 
route, except the lumbar, offers 
so many advantages in after- 
treatment (Fig. 140). 

While for prognostic pur- 

, , , Fig. 138. — Transpleural Route 

poses It IS important to know IN Subphrenic Abscess. 

whether the pleurae are adherent 

or present a cavity filled with serum or pus, so far as surgical 
procedures are concerned it makes very little difference. The 
adversaries of the transpleural route maintain that to open the 
pleural sac, if it be in a normal state, would expose it to the 
dangers of pneumothorax, as well as to infection from the 
atmosphere or from the escaping pus. 

Regarding the first objection, pneumothorax, it must be 
borne in mind that in subphrenic abscess the aspirating 
power of the diaphragm is greatly impaired. As is evident 
by the dullness found on percussion, the diaphragm is pushed 
so far up toward the thoracic cavity that it is pressed against 




286 Subphrenic Abscess. 

the thoracic walls to a considerable extent, and has its summit 
brought into permanent contact with the costal pleura. It 
may even be so overstretched as to be entirely paralyzed. 
Furthermore, the lower part of the thorax itself is generally 
expanded, thus diminishing its aspirating power. WTien 
pneumothorax does occur after the exposure of the pleural sac, 
and a feeble patient suffers shock, final incision and evacuation 
may be deferred until the following day. 

In reference to atmospheric infection, the author may refer 
to Petri's and Cleves-Symmer's experiments, which demon- 
strated bacteriologically what had long appeared probable 
from clinical observation, viz., that the microbes contained 
in the atmosphere are non-pathogenic under ordinary circum- 
stances. Furthermore, he does not see why the pleura should 
be more inclined to become infected than other parts of the 
body, provided thorough aseptic precautions were observed. 

While the incision should be made in the centre of the dull 
area, the exploratory needle will always indicate its ultimate 
route. The technic of the operation is practically the same 
as that of resection of a rib for pyothorax (see Figs. 83, 84, 85, 
91). As a rule, the eighth, ninth, or tenth rib is selected. 
The author prefers the median axillary line, as thence the 
abscess walls can be reached equally well in front and behind. 
It also enables the patient to be brought to the edge of the table 
during the operation, and permits him to assume the dorsal 
decubitus; while, if the incision were made farther back, 
he would be obliged to lie on the healthy side, thus rendering 
evacuation more difficult. If, however, the dull area, as it 
sometimes occurs in abscesses of small extent, is situated dis- 
tant from the median axillary line, the resection must take 
place at the point where the aspiratory needle revealed the 
pus. 

It goes without saying that thorough aseptic precautions 
must be taken. 

If the pleural sac be found empty the pus cavity is located 



Operative Technics in Subphrenic Abscess. 287 

by means of the exploring needle, and an opening is made 
through the diaphragmatic pleura just large enough to permit 
the introduction of a grooved director. Before this, aseptic 
tampons are packed around the pleural sac to occlude it from 
the escaping pus. As soon as pus appears in the groove of 
the director, a, small Pean forceps is introduced and the open- 
ing gently dilated. Evacuation of the pus must take place 
slowly. A sponge should be pressed against the opening from 
time to time to interrupt the stream, so as to avoid too rapid 
expansion of the lungs. If the condition of the patient permit, 
the finger is now introduced and any solid masses, such as 
fibrinous clots or necrosed tissue adhering to the abscess wall, 
are wiped out with the index-finger or with a blunt spoon made 
for this purpose. For inspection, the author's dilating specu- 
lum can sometimes be used to advantage. If haemorrhage 
should occur or if signs of shock be present, such procedures 
may be deferred for a day or two, as may also irrigation of 
the cavity with a sterile salt solution, which is used to secure 
thorough evacuation. When malodorous pus is found, an 
antiseptic wash, preferably bichloride, 1 to 10,000, is used 
for this once, instead of the sterile salt solution. 

The pleura or the edges of the diaphragm are stitched to 
the skin with four silk sutures (preferably iodoform silk), one 
at each end of the wound and one on each side, with strong 
Hagedorn needles. Thus the wound surface is entirely cov- 
ered and the adjacent tissues protected against infection. 
At the same time secondary haemorrhage is thereby prevented 
and the wound kept open. Then the cavity, if of small extent, 
is packed with iodoform gauze. If large, a rubber drain may 
be introduced besides. 

It is only after the rigorous procedures described above 
that the cavity can be pronounced entirely evacuated. No 
necessity of subsequent irrigation arises, which, besides being 
irritating, destroys those very adhesions which are much 
needed for the obliteration of the cavity. When the discharge 



288 



Subphrenic Abscess. 



becomes serous and scant, a small strip of iodoform gauze or a 
wick suffice to absorb the secretion. Now the patient must 
be watched very carefully, because the cavity may be obliter- 
ated after twenty-four hours, but very often the union is only 
superficial and retention of pus occurs, as shown by an eleva- 
tion of temperature. In such a case reopening is indicated, the 
same manoeuvre to be repeated after a week, until for about 
four days after the obliteration of the pus cavity no discharge 
appears and the temperature re- 
mains normal. In a doubtful case 
careful introduction of a grooved 
director through the scar tissue may 
reveal the presence of retained pus. 
The dressing should be changed 
every day for the first week; later 
every two days, and after three 
weeks it will suffice to change the 
dressing every third or fourth day. 
The patient, if at all able, 
should get up after one week. 
During after-treatment, for the 
first few days small doses of 
morphine are administered for the 
purpose of immobilization. If the 
pulse be weak, strophanthus or caf- 
feine may be added. Nourishment 
is given frequently and in small 
quantities to avoid overdistention of the stomach. 

Full anaesthesia should be administered only if the pulse 
is strong. As to further details regarding anaesthesia see sec- 
tion on pyothorax (page 159). 

If resection for subphrenic abscess is done anteriorly, an 
incision must be made from the anterior axillary line between 
the seventh and eighth rib (see Fig. 139). Having divided the 




Fig. 139. — Anterior Resection 
in the Seventh Intercos- 
tal Space. 



Lumbar Route in Subphrenic Abscess. 289 

fascia of the external oblique muscle, the seventh and eighth 
ribs are exposed and resected. The further procedures are 
the same in this operation as described above. 

The lumbar route (Fig. 140) merits special consideration 
in subphrenic abscesses of perinephritic origin. The incision 
in such cases should begin on the prominence of the sacro- 
lumbalis muscle and extend to the anterior axillary line. After 
the thick lumbo-dorsal fascia and the latissimus dorsi and 
serratus posticus inferior muscles are cut through, the sacro- 




Fig. 140. — Lumbar Route. Incision Passing under the Twelfth Rib. 

lumbalis muscle is drawn toward the spinal column. The 
lumbo-costal fascia is next divided. Now the quadratus lum- 
borum muscle appears running vertically, parallel to the 
border of the sacro-lumbalis muscle. A grooved director, 
introduced alongside the outer margin of this muscle, will 
lead to the pus cavity, which after being carefully and slowly 
evacuated, must be packed with gauze, preferably iodoform 
gauze (3 per cent.). The after-treatment should be conducted 
according to the principles of aseptic open-wound treatment. 



CHAPTER VI. 

DISEASES OF THE BREAST. 
ANATOMICAL PART. 
The mammae, breasts (ubera in animals), are two pectoral 
organs, serving as external accessory glands of the generative 
system. In most animals they are situated on the abdomen. 
The monkey carries it at the lateral region of the anterior chest 
surface, while in the human female they are attached to the pec- 





Fig. 141. — Mammilla and Its Areola (a) in a Virgin; (b) in a Pregnant 
Woman. 
1, Mammilla. 2, Areola. 3, Morgagni's and Montgomery's tubercles. 4, Fur- 
rows at the mammillary base. 5, Mammary integument. 5', Secondary areola. 6, 
Haller's venous circle. 

toralis major muscle and extend from the intervals between the 
third and seventh ribs and from the lateral margin of the ster- 
num to the axilla. The mammas are the characteristics of the 
first category of the vertebrates, wherefrom they are termed 
" mammalia." 

290 



Anatomy of Mamma. 



291 



The shape of the mammae is hemispherical and depends, 
just as much as its size, upon various conditions, among which 
the age and the natural physiological changes, the nationality and 
the climate may be mentioned. Near the middle each mamma 
is surmounted by the nipple (mammilla), a small wart-like 
prominence, the surface of which is colored by dark pig- 
ment. It is surrounded by a circular brownish area, called the 
areola. In virgins the areola is more of a rosy tint. The nipple 




Acini of 
gland 



Fig. 142. — The Female Mamma during Lactation. — {Morris, after Luschka.) 



is wrinkled and possesses a large number of papillae. At its tip 
it is perforated by the orifices of the lactiferous ducts. 

A sulcus, running parallel to the sternum, separates both 
mammae from each other. It is called the sinus. 

In the male the breast remains in a rudimentary state, but 
there are cases in which lactation was kept up for months. A. 
Humboldt reports the case of a man who nursed his child during 
the illness of his wife for four months. 

The secreting part of the mamma consists of ten to sixteen 



292 Diseases of the Breast. 

compound racemose glands, which are connected by fibrous 
tissue, the latter investing the entire mammary surface. The 
excretory ducts (lactiferous or galactophorous ducts, ductus 
lactiferi or galactophori) of these glandular lobes converge to- 
ward the base of the nipple, beneath which they become dilated 
into reservoirs, called ampullae (sinus lactei), and without under- 
going anastomoses terminate at the summit of the nipple, form- 
ing constricted orifices between the wrinkles of the nipple near 
its apex. 

The walls of the ducts consist of connective tissue mixed 
with elastic fibres and appear thinned at the terminal acini. 
Their calibre is constricted by a rich structure of cylindrical 
epithelium. The development of the acini does not begin 
before puberty. 

The presence of circular and radiating fibres of unstriped 
muscle permits nipple as well as areola to contract. 

The surface of the mamma and the interval between its 
lobes are mostly taken up by abundant adipose tissue, upon the 
extent of which the size and form of the organ largely depends. 

The arteries of the breast are derived from the arteria 
mammaria interna and the axillaris. The veins terminate 
correspondingly. 

As to congenital malformations of the breast see section on 
malformations, page 53. 



DISEASES OF THE NIPPLE. 

The skin of the nipple is very thin and tender. This 
accounts for the frequent occurrence of excoriations, in nursing 
mothers. The superficial epithelium is macerated by the re- 
peated acts of motion and friction, and if there is want of 
cleanliness, bacteria gain free access and cause infection. 

To prevent cracking of the nipples, washing with a saturated 
solution of boric acid immediately after nursing is advisable. 



Eczema of Nipple and Paget's Disease. 293 

If there are marked signs of inflammation, application with 
Lugol's solution . should be made. When fissures have 
formed, they should be washed with a 5 per cent, solution of 
chloride of zinc. 

The same rules apply to the treatment of eczema of the 
nipple, which is more or less caused by lack of cleanliness. 
The crusts must be removed, which is best done by gradually 
softening them up with moist applications (1:10,000 bichlorid 
of mercury). 

If an eczematous area assumes a red granular or excoriated 
appearance, and discharges a yellowish viscid secretion, we 
speak of malignant dermatitis or Paget's disease, which is 
characterized by the continuous presence of more or less 
lancinating pains. There is a marked tendency to spread far 
below the areola. 

Local treatment before the Rontgen era always proved to 
be a failure, the only remedy consisting in amputation of the 
breast. Nowadays the Rontgen treatment is usually successful. 

Observation showed that about two years after the onset of 
Paget's disease carcinoma developed, another corroboration 
of the assumption that integumental epithelioma originates 
from an epithelial proliferation at the skin surface. 

The areola is sometimes the seat of suppuration in girls 
about the age of puberty. This process originates in the 
sebaceous follicles and is treated after general surgical princi- 
ples. 

In engaging a wet-nurse great care must be exercised in 
examining the nipples, as there are chancres found some- 
times. Primary epithelioma is rarely found in the nipple. It 
demands amputation of the breast. 

Papilloma and sebaceous cysts are also observed. They 
require simple excision. 



294 



Diseases of the Breast 



INFLAMMATORY PROCESSES IN THE BREAST 
(MASTITIS). 

The peculiar structure of the mammary gland, especially 
the large number of ducts and alveoli, and besides the compli- 
cated arrangement of the lymphatics (Figs. 143 and 144), makes 
it a favored seat for inflammatory processes. Mastitis is ob- 
served during every period of life, but its marked prevalence 
is in nursing mothers. 



Brachial group Central group 




Anterior 

pectoral 

chain 



Duct from the 
mammary 



Anterior pectora 1 

node 
Duct from the 

mammary 

gland 
Collecting duct 

Subareolar 
plexus 

Duct from lateral 
thoracic wall 

Duct passing to 
internal mam- 
mary node 

Collecting ducts 

Duct passing to 
internal mam- 
mary node 



Fig. 143. — The Axillary Lymph-nodes. — (Morris, after Poirier and Cuneo.) 

In the new-born swelling of the mammary glands, asso- 
ciated with redness of the skin, is often seen. In most cases 
a clear or milky secretion can be squeezed out. The aetiology 
of this phenomenon is unknown. The treatment consists in 
applications of Burow's solution. Sometimes there is suppu- 
ration, in which case an incision is to be made. 



Ducts from network 



Lobule of 
gland, un- 
infected 




Ducts from network 

Fig. 144. — Lymphatics of the Subareolar Plexus of the Breast. — (Morris, 
after Sappey.) 



Pyramidal 




Fig. 145. — Horizontal Diameter of the Right Mamma. — (Morris* "Anatomy") 

295 



296 



Diseases of the Breast. 



During puberty girls as well as boys show a painful intu- 
mescence of the mammary gland sometimes, which becomes 
much enlarged and hardened. The areola appears pig- 
mented and reddened then. As a rule, the swelling subsides 



Pectoralis major- 



Retinaculum cutis 
Pyramidal process 




Lactiferous duct 
Lactiferous sinus 



Pyramidal process 

Rectinaculum cutis ^ at 



External oblique 

Fig. 146. — Sagittal Section of the Right Mamma of a Woman Twenty-two 
Years Old. — {Morris, after Testut.) 



after two or three weeks, but in some instances the gland 
remains enlarged to double its size for many weeks. It may 
still disappear then, but sometimes suppuration is the final 
outcome. Then, of course, a broad opening is to be made. 



Puerperal Mastitis. 297 

Mastitis may also occur in non-puerperal women as the 
result of an injury, or of pyaemia. 

After the disappearance of the swelling in infectious paro- 
titis a metastatic form may be observed in the mammary 
gland. 

Puerperal mastitis is by far the most frequent type of in- 
flammation of the mammary gland. It originates from a sore 
or cracked nipple, which presents the avenue of infection, the 
pyogenic cocci invading the lymph-channels or entering the 
milk-ducts directly. 

As a rule, the first signs of puerperal mastitis manifest 
themselves during the first four weeks after confinement, espe- 
cially after the third week. In the incipient stage only a few 
lobuli are infected, and if early surgical interference is sought, 
the infection may remain confined to a circumscribed area. 

The signs of acute mastitis are fever — as a rule, heralding 
itself by a chill. The breast becomes intensely painful and 
swollen, so that nursing can hardly be tolerated by the mother. 
One or another glandular nodule appears to be enlarged or 
indurated. On pressure the pain is increased. The inflam- 
mation spreads gradually until the periphery becomes involved. 
The presence of oedema is ascertained by digital pressure, which 
produces a groove in the skin. If surgical interference is post- 
poned, the whole breast will finally participate (see Fig. 147). 

In those rare cases of acute mastitis in which the symptoms 
are of a mild nature, expectant treatment is justifiable in the 
incipient stage. Then the inflamed mamma needs to be sup- 
ported by a sling, preferably of gauze, and treated by moist 
applications. When the inflammation subsides, compression 
must be exerted by a muslin bandage (Fig. 148). How far com- 
pression after Bier's method is apt to check inflammation, is 
not sufficiently proved yet. In selected cases the new method 
has certainly aborted the inflammation. 

But in the far greater majority of cases puerperal inflam- 



298 Diseases of the Breast. 

mation of the breast leads to suppuration. Proper treatment 
consists in early incision. 

This must be large, so that the surgeon is able to introduce 
his finger into the abscess cavity. By doing this it will often be 
found that there are several abscess cavities, which are sepa- 




Fig. 147. — Inflammation of Left Breast Five Weeks after Puerperium. 
Note extensive pigmentation caused by previous dermatitis. 

rated from each other by a wall consisting of more or less 
degenerated or even necrotic tissue (Fig. 150). Such tissue 
is only detected by the introduced linger, which at the same 
time frees it, so that the debris can be washed out by irrigation. 



Evacuation of Mammary Abscess. 299 

If these masses are left, they become decomposed in spite of 
frequent irrigation. 

Besides this they prevent thorough evacuation of the neigh- 
boring abscess cavities. If an incision is made then at the 




Fig. 148. — Compression Bandage (Figure-of-eight). 

fluctuating point only, there is but temporary relief, the feb- 
rile condition still persisting, as the other abscesses also make 
an effort to perforate in different directions. A large incision, 
which combines all abscess cavities, so that one large cavity 



300 Diseases of the Breast. 

is formed from which all necrotic fragments are removed, is 
the only procedure which answers the demand of modern 
surgical principles. This can be done bluntly sometimes; in 
the majority of cases a sharp spoon or scissors and forceps are 
required for the thorough elimination of the masses. To get 
good access the wound-margins are kept separated by retrac- 
tors. The cavity is packed tightly with gauze on the first day, 
as there is considerable oozing. On the following day pack- 
ing may be done loosely. 

Sometimes the abscesses are located in the subcutaneous 
tissue or only in the superficial lobules (supra/mammary abscess). 
The principles of treatment are the same in this mild form, but 
it is immaterial in which direction the incision is made. In 
the common type of intramammary abscess, where the 
pus has distended the lobules and infiltrated the enveloping 
connective tissue, the incision line must radiate from the 
nipple, in order to prevent injury to the ducts. If this incision 
is made long enough and the cavity well exposed, no additional 
incisions ever become necessary. 

The rarer type, called retromammary abscess, spreads 
from the deep lobules, in which case the whole gland is pushed 
forward so that it floats, so to say, on a purulent bed. There 
a large elliptic incision is best made at the base of the breast, 
where fluctuation is most marked. Otherwise the principles 
of treatment are the same. Of course, if previous incisions 
were made, their fistulous tracts may be divided, so that one 
large cavity is formed (Fig. 149). 

The operations for mammary abscess can, as a rule, be done 
under local anaesthesia (ethyl chloride or Schleich's infiltra- 
tion) . 

One of the sequelae of mastitis is extensive cicatrization, 
which results in a shrinkage of the gland. This may in a later 
period of life give an impetus to the development of carcinoma. 
In other cases cicatrization may obstruct a duct, so that the 



Chronic Mastitis. 301 

secretion is retained at the point of obliteration and dilates the 
canal like an ampulla, thus giving rise to the formation of 
galactocele. 

The treatment of galactocele consists in free division and 
packing. If operative interference is deferred, the retained 
milk becomes thickened at first and presents an oily or batter- 
like appearance later. In some instances the fluid contents are 
absorbed and mortar-like connections form. 




Fig. 149. — Seven Fistulous Tracts United into One Large Opening in Old 

Retromammary Abscess. 



Chronic (Interstitial) Mastitis. — This is a type of mas- 
titis observed shortly before or after the menopause, which is 
characterized by the formation of dense or circumscribed infil- 
trations in the mammary gland. Its course is chronic. Its 
similarity to carcinoma is so much more obvious as there are 
often swollen glands present in the axillary region. In tegu- 
mental inversion is also observed sometimes. This form of in- 



3 02 



Diseases of the Breast. 



flammation generally starts synchronously on both sides. In 
contradistinction to carcinoma, size and consistency of the 
inflammatory area change often. The diagnosis is sometimes 
made ex juvantibus et nocentibus. Iodide of potassium in 




Fig. 150. — The Principal Types of Mammary Abscess-formation. 
1. Muscularis pectoralis major. 2. Retromammary space. 3. Third rib. 4. 
Intercostal spaces. 5. Lung and pleura. 6. Subcutaneous tissue, a. Submammary 
abscess, a". Opening into the subcutaneous tissue, b and d. Isolated mammary 
abscesses, c. Circumscribed areolar abscess, e. Subcutaneous abscess. 



medium doses (15 to 20 drops of a saturated solution t. i. d.), 
applications of blue ointment, or massage are generally effi- 
cient, if the diagnosis was correct. Recently the Rontgen 
treatment has also given good results in such cases. 



Chronic Lobar Mastitis. 



3°3 



As to differentiation it may be said, however, that in such 
cases usually both breasts are involved and that the mammary 
gland participates in its totality, while at the early stage of 
carcinoma a small portion is palpable only. The skin is 
generally movable and entirely free from the infiltrated mass, 
which never adheres to the pectoral fascia. While axillary 
glands are sometimes found, they are more frequently absent 
and never as hard nor as much enlarged as in carcinoma. 




Fig. 151. — Chronic Interstitial Inflammation in Left Breast of a Woman 

of Forty-one Years, Cured by Internal and Rontgen Treatment, 

Note brownish hue of left areola while the right is normal, also slight inversion of 

the left nipple. 



The author called attention to the frequent pigment formation 
in the areola of the breast in chronic inflammation. Small 
nodules are also found sometimes in the diseased areola (Fig. 

151)- 

Chronic lobar mastitis is a much rarer type of chronic 
inflammation. It is either caused by trauma (blow or squeeze) 
or by incomplete involution at the cessation of lactation. The 



304 Diseases of the Breast. 

inflamed lobule is enlarged and the patient suffers considerable 
pain, which is increased during the period of menstruation. 

The treatment consists in supporting the gland and keeping 
the arm of the inflamed side in a sling. Warm applications of 
Burow's solution are also advisable. 



MAMMARY CYSTS. 

Galactocele as a result of cicatricial obstruction of the ducts 
was mentioned in the foregoing section. Their walls are lined 
with epithelium of the columnar or cuboidal types if a part 
of the lobe or of the duct is involved. If the cyst enlarges the 
epithelium may be flat and squamous or may become sur- 
rounded by a fibro-cellular layer. 

If cysts form in chronic interstitial inflammation, they are 
called involution- cysts. Cystic dilatation may also be ob- 
served in association with carcinoma or papilloma of the ducts, 
or in cystadenoma. 

Cysts which develop in the interstitial tissue are called 
interacinous, and are either of a serous nature or represent 
the type of hydatids or dermoids. 

The serous variety is the result of a dilatation of the lymph- 
spaces and is either uni- or multi-locular. Its lining is a smooth 
epithelial layer. It contains serum, slightly tinged with blood. 
In old cases colostrum is also found. Not being in direct 
connection with the gland, the serous cyst does not show any 
discharge from the nipple. If the cyst- wall remains thin, 
translucency is noticed, just as in hydrocele. 

Regarding differentiation from carcinoma, it should be 
appreciated that the serous cyst shows elastic resistance on pal- 
pation, while carcinoma is characterized by its hardness. Re- 
traction of the nipple or enlargement of the axillary glands is 
never observed. In case of doubt exploratory aspiration with 



Tuberculosis Mammae. 305 

a large needle will clear the situation. The treatment should 
consist in thorough removal. 

The other cyst-types are rare and their treatment is essen- 
tially the same. Cysts originating from adjacent carcinoma- 
tous or sarcomatous tissue require no special consideration. 



SPECIAL INFLAMMATORY PROCESSES IN THE 
MAMMARY GLAND. 

The special inflammatory processes in the mammary gland 
are tuberculosis, actinomycosis, and syphilis. 

Tuberculosis mammae is rare and is nearly always found 
in the female, especially in anaemic individuals, who present the 
tuberculous habitus. It is never observed before the period of 
puberty. Its avenues of infection are either the ducts or the 
circulation. The bacillus may also be transmitted from the 
neighboring organs, viz., the ribs, the pleura, or the axillary 
glands. 

The clinical signs vary greatly. There may be a circum- 
scribed abscess in the gland, which causes its enlargement, 
so that an elastic and fluctuating intumescence is palpated, 
while the integument is entirely normal. If an incision is made, 
cheesy sero-pus is discharged. The abscess cavity shows the 
same lining membrane which is found in so-called cold ab- 
scesses. In other cases the character is diffuse, tuberculous 
nodules being scattered and then developing in the interacinous 
tissue. Pus is forming and perforates the skin at various 
places, so that the breast is finally riddled with sinuses which 
discharge cheesy pus. The nipple becomes inverted, while 
the base of the gland remains freely movable. The axillary 
glands are swollen and show the signs of caseous degeneration 
and destruction. 

In the incipient stage the diagnosis is sometimes difficult. 
Later, when fistulaa form, tuberculosis is obviously thought of, 



306 Diseases of the Breast. 

as the character of the discharge and microscopical examina- 
tion corroborate the diagnosis. In cases of doubt inoculation 
of a lower animal settles the question. 

The treatment consists in the amputation of the mammary 
gland and the evidement of the axillary space. The after- 
treatment is essentially the same as in carcinoma mammae 
(see page 328). If the process was confined to the gland, the 
prognosis is favorable. 

Actinomycosis mammae is very rare. The diagnosis is 
made on the principles described in actinomycosis of the ribs 
(page 10 1). The treatment consists in ablation of the mam- 
mary gland. Successful operations' are reported by Ammer- 
torp, Muller, and von Angerer. 

Syphilis mammae is rare. As mentioned before, a pri- 
mary lesion may be observed on the nipple. Tertiary forms 
assume the character of superficial as well as of deep-seated 
gummata. The treatment is internal (inunctions with blue 
ointment combined with the administration of iodide of potas- 
sium); the author also favors the long-continued administra- 
tion of protojoduretum hydrargyri in pill form. 1 



ECHINOCOCCUS OF THE MAMMARY GLAND. 

Echinococcus of the mammary gland is rare, especially in 
the United States of America. The signs resemble those of 
ordinary cyst formation, as described (page 304). Their 
onset is slow and painless. In case of irritation by trauma 
inflammation and suppuration may take place, so that the 
echinococcus-cyst is taken for an abscess. The treatment 
consists in the thorough extirpation of the sac. 

1 I^. Protojoduret. hydrargyri, 

Opii puri, aa 0.3. 

Extr. acori, q. s., ut f. pilul. No. xxx. 
SiG. — Three pills a day. 



Neuralgia and Hypertrophy of Breast. 307 

NEURALGIA OF THE MAMMARY GLAND 
(MASTODYNIA). 

Mastodynia occurs in breasts which are apparently normal. 
Hysteric women are especially subject to it. Frequently it is 
associated with disturbances of the sexual sphere, also with 
intercostal neuralgia. 

The pain becomes intensified shortly before menstruation, 
the patient then often being in a state of great nervous excite- 
ment. Sometimes small indurations (neurofibroma) are found 
in healthy individuals. The treatment must be directed 
against the fundamental factors. Thus a cure is effected by 
gynaecological treatment in the majority of cases. If this 
should not alleviate the pain, local therapy should be tried, sus- 
pension of the breast, hot applications, electricity, etc. The 
author has observed surprising relief in one of his cases from 
exposure to the Rontgen rays. 

HYPERTROPHY OF THE BREAST. 

Benign hypertrophy of the breast is observed at the 
period of puberty, or in young pregnant women in the great 
majority of cases (Fig. 152). As a rule, both breasts participate 
in the swelling, which develops in a few months. The sub- 
stance of the gland, as well as the interstitial tissue, become 
involved in the hyperplastic proliferation, which is of a fibro- 
adenomatous character. The whole mammary gland appears 
indurated then, growing so large that it hangs down as 
far as to the umbilicus. Pain is generally absent. The 
weight of the hypertrophied breasts causes functional disturb- 
ance, whereupon partial as well as total amputation was 
resorted to. Fig. 153 illustrates the case of a woman of thirty 
years, in whom keloid-formation followed partial excision. 
The internal treatment of this disease does not show any 



3 o8 



Diseases of the Breast. 



In men the mammary glands develop to such an extent, 
sometimes, that they appear like female breasts (gynecomastia). 
In these rare cases the glandular, fatty, and connective tissue 
is overdeveloped. 




Fig. 152. 



-Hypertrophy ,of Both Breasts in a Woman of Twenty-five 
Years. 



TUMORS OF THE MAMMARY GLAND. 

Tumors of the breast are extremely frequent and show a 
large number of varieties, the differentiation of which is often 
difficult. For practical reasons we may distinguish benign and 
malignant tumors. In general, we may say that the benign 



Tumors of Breast. 



309 



tumors consist of homologous tissue, that is, of such tissue 
as is found on their own soil, as, for instance, fibroma 
and adenoma. The malignant tumors consist of heterologous 
tissue, that is, of such tissue as is not found on their own 
soil, as, for instance, sarcoma and carcinoma. 

There are, however, some exceptions to this general rule. 
Enchondroma is a heterological type and is still mostly of a 
benign nature. 




Fig. 153. — Keloid Formation after Partial Excision of Hypertrophieo 
Breast. 

It is one of the characteristics of the benign tumors that 
they remain circumscribed and well defined from their vicin- 
ity. They push the adjacent tissue aside only, while the malig- 
nant tumors permeate and infiltrate it. This is the main reason 
why benign growths are freely movable. 

Benign tumors are generally found at an early age, carci- 
noma, for instance, rarelv being observed before the thir- 



3 io 



Diseases of the Breast. 



tieth year, while fibroma is generally found at the period of 
. puberty. The family history often gives some hints regarding 
malignancy. 

The relation of the tumor to the mammary gland, as well 
as its form and consistency, must be elicited by a careful ex- 
amination. It must be ascertained whether there is any fluctu- 
ation, whether mobility exists, and whether this be superficial 
or deep. Any protrusion of tumor or gland must be noted, as 
well as dimpling of the integument, and the appearance of 
the nipple (Fig. 1 54) . Both breasts must be carefully compared . 
The axillary relations should also be investigated, while the 
arm is raised. 




ABC 
Fig. 154. — Sagittal Diameter of Various Deformities of the Mammilla. 
A, Normal mammilla. B, Shortness of the mammilla. C, Invagination of mammilla. 
D. Umbilication of the mammilla. E, Retraction of mammilla in cancer. 



It must furthermore be elicited at what time the tumor was 
detected at first. The more rapid the growth of the tumor 
is, the greater is its abundance of cells; consequently, the 
softer and the more vascular it will be. 

The further course of malignant tumors is characterized 
by cachexia. 



ADENOFIBROMA (FIBROADENOMA). 
Adenofibroma is the most frequent representative of the 
benign type in the breast. It is especially observed in indi- 



Benign Tumors of Breast. 311 

viduals between the ages of twenty and thirty, in rare cases up 
to the fortieth year. Its etiology often points to a trauma. 
Its size varies from that of a filbert up to a man's head. Most 
of these growths remain small for years. 

Its main characteristic is its free mobility. The consistency 
is firm and hard. If increasing in size, it may become elastic 
on some portions. Pain is generally absent, but sometimes 
found in neurotic women. The shape is globular or oval, and 
the surface smooth. The tumors are encapsuled, which 
explains that they never invade the surrounding tissues. 

Anatomical examination shows a foliated texture, like cab- 
bage, of a gray or whitish color. The tumor is composed of 
glandular elements, which are imperfectly developed, but show 
the type of the mammary gland. They are enveloped by firm 
connective tissue. 

The treatment is distinctly surgical, enucleation being gen- 
erally possible under local anaesthesia. The direction of the 
incision must be radiating from the nipple. 

ADENOMA. 
Pure adenoma is extremely rare. In the great majority of 
cases it is confounded with adenofibroma, its characteristic 
features being recognized by microscopical examination only. 

LIPOMA, ATHEROMA, MYXOMA, ANGIOMA, CHON- 
DROMA, AND OSTEOMA MAMMAE. 

All these tumors are of rare occurrence. Lipoma is easily 
recognized, as it can be well defined from the gland. It origi- 
nates either laterally or posteriorly of the mammary gland, 
which it pushes aside. Sometimes lipoma mammae reaches 
large size. 

Atheroma (syn., cholesteatoma) mammae resembles seba- 
ceous cyst, its fatty contents consisting of cholestearin-like 



312 Diseases of the Breast. 

substances. The cyst-wall is thin and can be easily enucleated. 
It consists of connective tissue, lined with epithelium. 

Myxoma as well as angioma mammae are extremely rare, 
and their clinical course shows the same features as adenofi- 
broma. 

Chondroma and osteoma are also rare. If there is any 
doubt as to their nature, the Rontgen rays will furnish infor- 
mation as to the character of their texture. 



SARCOMA OF THE MAMMA. 

Sarcoma mammae is very much less frequent than carci- 
noma. Among the tumors of the breast sarcoma figures with 
about 88 per cent., the predominant type being the spindle-celled. 
Most of the cases show cystic degeneration at the same time. 
The spindle-celled sarcoma and also the cystic variety are 
especially found in women of the age of twenty to thirty-five 
years. Both types are characterized by their slow growth. 

The spindle-celled sarcoma mammae (Fig. 155) is of glob- 
ular or oval shape and at its initial stage is easily confounded 
with adenoflbroma. But in its further course it shows close 
connection with the adjacent tissue, which it soon permeates 
and infiltrates. The microscopical examination, however, 
must be principally relied upon for an exact diagnosis. 
The axillary glands are but rarely affected. 

When the diagnosis is made, extensive removal of the 
breast after the principles of extirpatio mammae in carcinoma 
is indicated. 

The same applies to the round-celled sarcoma mammae 
(Fig. 156), which is softer than the spindle-celled and more 
elastic. It soon permeates the adjacent tissue and grows 
rapidly. Often metastases are found in the axilla. Sometimes 
metastatic nodules are found through the whole body. Cystic 



Sarcoma Mammae. 



3 J 3 



as well as myxomatous degeneration is also frequently observed 
in this type. 

Its predilection is for women between the ages of thirty 
and forty. Its rapid growth, the absence of integumental dimp- 
ling and of retraction of the nipple are pathognomonic signs in 




FiG'155. — Fibrosarcoma Mammas (Spindle-celled) in a Woman of Twenty- 
three Years. 



contradistinction to carcinoma. The treatment is the same as 
that of the foregoing variety. 

The other types, viz., the giant-celled, the medullary or 
alveolar, besides angio-, lympho-, chondro-, and melano-sarco- 
mata, practically fall under the same consideration. After 



314 Diseases of the Breast. 

extensive removal Rontgen treatment at intervals should be 
given for at least a year. (As to the principles of the technic, 
see following section.) 




Fig. 156. — Incipient Stage of Cystic Sarcoma (Round-celled) in a Woman 
of Twenty-one Years. 



CARCINOMA MAMJVLE. 

Excepting uterus and stomach, no other organ of the hu- 
man body is so frequently the seat of carcinoma as the mam- 
mary gland in women. In men carcinoma of the breast is 
observed about a hundred times less frequently. The author 



^Etiology of Cancer. 315 

observed five cases, all of which were operated upon, and suc- 
cumbed finally after repeated recurrence. 1 

The marked disposition of the mammary gland to can- 
cerous degeneration is well understood, if the repeated changes 
in its functional activity — its abundant blood-supply (see Figs. 
141, 142, 143, and 144) — as well as the relations to the sexual 
organs are considered. All movements which cause frequent 
and intense fluctuations in its state of nutrition as well as in 
its development, explain the tendency to metamorphosis. That 
it is preeminently the function of the gland, which is to be re- 
garded as a predisposing factor, is evident from the fact that 
carcinoma mammae is never observed before puberty. At the 
climacterium the gland undergoes a process of fibrous degen- 
eration, which must be considered normal, but there is no 
doubt that during this period the gland is more inclined to 
heterological metamorphosis than at any other. 

The author has seldom seen a case in which the patient did 
not attribute her carcinoma to an injury. But while there is 
no doubt that trauma is a contributing element in the aetiology 
of carcinoma mammae as well as in other malignant neoplasms, 
there is no proof that it is the essential factor. No doubt, a 
blow or a squeeze is very frequently inflicted upon the breast 
without showing any ill consequences, and soon escapes the 
patient's memory, while if there is a growth, the occurrence is 
remembered well and the degree of violence generally exagger- 
ated. It seems that the continuous irritation exerted by a 
badly-fitting corset, is very apt to act as a predisposing element. 
If in cutting bread the loaf is pressed against the mamma, as is 
customary among some women, irritation may frequently be 
produced. Attention may also be called to the development of 
carcinoma in old scars (see Fig. 60), in lacerations of the cer- 
vix, in psoriasis of the tongue, in phimosis, in the scrotum of 
chimney-sweepers, on the lip and tongue of heavy smokers. 

1 "Clinical Recorder," October, 1896. 



316 Diseases of the Breast. 

Heredity may also be considered, but too much importance 
should not be attributed to it. 

As we know to-day, the morphological character of carci- 
noma is entirely epithelial. The cells of the carcinomatous 
tissue show epithelial structure, not only in regard to their 
nuclei and their protoplasm, but also with respect to their 
origin. As mentioned before, it is a characteristic feature of 
the tissue of malignant growths that it is decidedly hetero- 
logical. Therefore a connective-tissue cell cannot be trans- 
formed into an epithelial cell, nor can the latter be made from 
the former. Only the various kinds of epithelium can be 
transformed into another kind, as, for instance, a squamous 
cell can be transformed into one of a cylindrical type. So the 
essential element of carcinoma is the epithelial cancer cell. 
In some carcinoma types the epithelial cells are, in fact, the 
only cancer element present, as in the lumen of the lymph- 
vessels in the lungs or the uterus. In other types there is a well- 
marked stroma, the character of which would indicate nothing 
of special importance as far as the dignity of the process is con- 
cerned ; in other words, the stroma is simply an accessory con- 
stituent. Thus it is to be realized that every form of carcinoma 
is in reality an epithelioma. 

The carcinomatous varieties must then be determined by the 
various branches of the arrangement of the morphological and 
the biological nature of the cells. We may thus distinguish 
epithelial cells with a typical as well as with an atypical ar- 
rangement (Fig. 157). The variety which is characterized by 
the typical arrangement is of a glandular nature (adenomatous) 
and consists of cylindrical cells forming glandular canals (ducts) 
or shows an arrangement in strata. They resemble the epider- 
mis and are, therefore, generally called cancroids. In the atypi- 
cal variety the cells are arranged irregularly and are found in 
masses and patches. The different varieties are distinguished 
according to the special organs in which the parent growth 



Transplantation of Cancerous Tissue. 317 

has originated. This variety is the cancer par excellence. Be- 
tween these two large groups we find a number of varieties of 
mixed and transitional forms. Whether the limitless and 
aberrant growth of epithelial cells, which constitutes carcinoma, 
originates from a parasite, cannot be proved by our present 
means of knowledge. While the attempts to transplant carci- 
noma, that is, to produce an artificial metastasis, so to say, have 
been successful once in a while, so far a primary carcinoma 










38&f<Mi)^ 



Fig. 157. — Incipient Adenocarcinoma Mammae. 
a, Normal glandular tissue, b, Atypical glandular proliferation. 

could not be produced yet with any amount of certainty. All 
we can say at the present time is that we hope that the great 
institutions which were recently constructed for exclusive 
research in the carcinoma problem will bring us something 
more palpable. 

The experience gained by the Rontgen method in regard to 
the production of epithelioma by long-continued irradiation is 
not in favor of the parasitic theory. 



3* 



Diseases of the Breast. 




Fig. 158. — Ulcerating Fibrocarcinoma of Right Breast a Year after Its 
Onset, in a Woman of Forty-five Years, Anesthetized and Ready for 
Scrubbing. 




Fig. 159. — Ulcerating Adenocarcinoma of Left Breast, Nine Months after Its On- 
set, in a Woman of Fifty Years. 
Note swelling of axillary glands. 



Glandular Carcinoma Mammae. 319 

All these general considerations apply to carcinoma mammae 
just the same. According to these the acinous or glandular and 
the duct-carcinoma may be distinguished. 

The glandular variety (scirrhus) begins as a dense and 
circumscribed mass and generally establishes itself at the 
outer half of the gland. As mentioned above, it is tightly im- 
bedded in the tissues. At the incipient stage the integument is 
freely movable above the neoplasm, but later it becomes more 
and more adherent. At last there is marked fixation, so that 
there is dimpling as soon as there is an effort made at displace- 
ment. Finally the tumor adheres to the pectoral fascia or 
even the pectoralis major muscle. In the majority of cases 
there is little, if any, pain. As a rule, the axillary glands be- 
come enlarged early. Later the infraclavicular glands parti- 
cipate also and in old cases intrathoracic deposits will form. In 
the further course of the disease the integument is more and 
more invaded, the area nearest to the tumor reddens, and 
finally an excoriation like deposit forms, which by degrees 
assumes the appearance of an ulcer. If not operated upon 
then, the sloughing ulcerations become larger and decom- 
position from the necrotic tissue causes an offensive odor and 
adds septic infection to the cachexia. 

In the minority of cases no ulceration takes place, the can- 
cerous nodules pervading the skin, which appears then like 
being lined with many button-like masses. Sometimes the skin 
is infiltrated in its entirety, so that it becomes indurated, and 
so much contracted that it appears like pig-skin. This process 
may spread over the whole thoracic wall, so that it forms a 
cuirass, so to say. In later stages the axillary vessels are 
compressed, so that the area becomes swollen and brawny. 
At this stage metastasis generally develops in the viscera. 

The duct-carcinoma distinguishes itself by the develop- 
ment of one or several nodules of a papillomatous character 
within the ducts, as a rule in the vicinity of the nipple. Their 



320 Diseases of the Breast. 

epithelium is columnar and their texture vascular. Their 
growth is slow, the nipple does frequently not become retracted 
and swelling of the axillary glands is often absent. Sometimes 
the dilated alveoli become confluent into a papillomatous mass. 
The exact diagnosis of this type is seldom possible without 
the aid of the microscope. Attention is called again to the 
clinical observation that neither the presence nor absence of 




Fig. 160. — Beginning Duct-carcinoma of Right Mamma in a Woman of Fokty 

Years. 
Note inversion of nipple and discoloration of diseased area. 

axillary glands or of retraction of the nipple prove any- 
thing for or against carcinoma, both conditions also being 
present in chronic inflammation. Its treatment is the same 
as that of the glandular variety. 

There is a rare type called encephaloid carcinoma, which 
is characterized by the rapid infiltration of the breast. In 
conformity with this is the quick formation of metastasis in 
the lymphatics and the viscera. There is no retraction 



Treatment of Carcinoma Mammae. 321 

of the nipple or integumental dimpling. The skin is pervaded 
rapidly, a deep fungating ulceration crater forming them. 
The prognosis of this typ'e is grave. Extensive removal at as 
early a stage as possible is imperative. Besides the varieties 
mentioned, psammous as well as chondro-osseous carcino- 
mata are observed sometimes. They fall under the same con- 
siderations. 

The differential diagnosis of mammary carcinoma hinges, 
as mentioned above, mainly on the density and hardness of the 
glandular type, its intimate union with the substance of the 
gland, limited mobility, the retraction of the nipple, the integ- 
umental dimpling, and the presence of axillary enlargement. 

Benign tumors are characterized by their free mobility, 
their circumscribed outlines, their more or less elastic con- 
sistency, the absence of retraction of the nipple and of axillary 
glands, as a rule. Sometimes distinction between sarcoma and 
carcinoma could be made, but this is of academic importance 
only, since the treatment is practically the same. 

Treatment. — The treatment consists in extensive removal. 
Since Volkmann found, on microscopic examination, that even 
in small and superficially located carcinomatous growths of the 
mammary gland, the fascia was generally involved, he was natu- 
rally led to the conclusion that removal of the tumor alone was 
an insufficient procedure. The correctness of his investiga- 
tions was corroborated by Heidenhain, who found carcino- 
matous cells in the superficial layer of the pectoralis major 
muscle, even when the breast was only superficially involved. 
From these observations we learned that dissection of the su- 
perficial layer of the pectoralis major muscle was not suffi- 
ciently radical, even when the carcinomatous nodule was but of 
small size. 

It did not take long for the conclusions of Volkmann and 
Heidenhain to bear rich fruits. The surgeons who followed 
Volkmann' s example were soon able to report cases which 



322 Diseases of the Breast. 

showed no signs of recurrence until after more than a year. 
Kuester, Senn, Halsted, Weir, Meyer, and the author advised 
still more radical steps, with more or less modification of the 
original method. 

The motto, "Better too much than too little," must be 
adhered to in malignant disease, as emphasized in the author's 
previous publications. It is better, therefore, to suffer from 
slight functional disturbances after sacrificing the whole pec- 
toralis major and minor muscles than to attain a good func- 
tional result followed by speedy recurrence. 

Even if a limited area is involved only, as in the case illus- 
trated by Fig. 1 60, a most extensive removal is indicated. The 
same thoroughness is required in regard to the infiltrated glands. 
It does not suffice to remove the axillary glands only if there 
are signs of intumescence in the deep subclavicular space. 
Whatever tissue appears to be suspicious must be removed, be 
it a gland or some other tissue. 

If we were to remove all the thoracic muscles, together with 
the infiltrated glands except a single small one, we would 
be in the same position as the surgeon who, after having car- 
ried out the most minute aseptic details during the operation, 
should finally pack his wound with an infected piece of gauze. 

In view of the immense importance of the axillary glands, 
their anatomy, and particularly their relation to their lymph- 
atic vessels, deserves careful attention (see Fig. 143). There 
are different groups, one descending from the superficial and 
deep-seated lymphatics of the neck, shoulder, and back; 
another one, also both superficial and deep-seated, coming 
from the arm; and a third one springing up from the super- 
ficial and deep-seated lymphatics of the mamma, the thorax, 
and the superior abdominal area. 

To the glands of the first group the serratus anticus major, 
the latissimus dorsi, teres major and minor, the suprascapular 
and infrascapular, subscapular, deltoid, trapezius, the rhom- 



Lymphatic Vessels of the Mammary Area. 323 

boidei, and sometimes the pectoralis major and minor muscles 
convey their lymph. The second group of glands is situated 
at the inner and lower margin of the axillary vein and also in- 
cludes the latissimus dorsi, teres major and subscapular, besides 
the serratus anticus major muscles. Of the third group it has 
to be borne in mind that its lymphatics from the abdominal 
and pectoral region permeate the pectoral glands, before 
they reach the axillary. There is one very important axil- 
lary gland always situated on a level with the third rib, 
which is first reached by the mammary lymphatics. From 
this gland the lymphatics lead to the superficial axillary glands 
and also to the gland that is sometimes found underneath the 
pectoralis major muscle. It can be seen without dislodging 
the pectoralis major, provided the fibres of this muscle are not 
too strongly developed; otherwise it will be covered by it. 
This anatomical fact shows that where this gland cannot be 
well exposed and made accessible without cutting into the 
muscle and dislodging it, this lateral portion of the muscle 
must be removed even if the most conservative views are held. 

If the infraclavicular region cannot be inspected thoroughly 
by pulling the tissues aside with retractors, the pectoralis 
major muscle may just as well be dissected up to the clavicle. 
Conservative surgeons unite the two fragments then after the 
search from axilla up to the clavicle is completed. Thus a 
muscular flap is formed, the basis of which is situated at the 
region of the upper arm. 

The most important part, however, in fact, the conditio 
sine qua non of success, is the thorough clearing of the axilla, 
which has always to be combined with the extensive exposure 
of the infraclavicular space. The pectoralis minor muscle 
needs to be removed only when it adheres to the in- 
fraclavicular glands. In the vast majority of cases this 
muscle can be dislodged, so that the area below is easily 
accessible. 



324 Diseases of the Breast. 

The technic of the operation, as it was practised by the au- 
thor until its recent modification (see page 331), is the following: 

1. The patient is prepared after the principles described in 
the section on asepsis (page 61). 

2. It is advisable to prick the integument first by circumcis- 
ing the gland at least two inches distant from the circumference 
of the growth (after Esmarch and Halsted). The nipple has 
always to be included. The incision is started from the ster- 
num, at the insertion of the fifth rib, and extended by passing 
underneath the nipple, to the arm at the insertion of the pecto- 
ralis major muscle. A second preliminary incision, reaching 
from the same point as that of the first incision, runs above 
the nipple into the first incision-mark at the lateral margin of 
the mammary gland, thus forming an elliptical or oval piece 
of skin. 

Now the skin around the elliptical piece is divided, as 
indicated by the preliminary incisions, and so far reflected 
that the mammary gland can be easily grasped with the full 
hand. So far the loss of blood is insignificant and can easily 
be checked by the use of a few haemostatic forceps. 

3. Grasping the elliptical piece containing the mamma 
with the full hand, and pulling it upward, an incision is made 
alongside the base-line of the lower skin-flap right down to 
the ribs, penetrating fascia and muscle at once. A long knife 
has to be used for this purpose. No time is wasted by using 
hcemostatic forceps, the assistant in charge controlling the haem- 
orrhage by pressing a long gauze compress against the bleed- 
ing surfaces. 

Now the same manoeuvre is repeated on the opposite side, 
that is to say, below the upper skin-flap, and the mammary 
gland pulled downward, thereby increasing the pressure upon 
the tamponed surfaces below. This incision, like the first one, 
starts from the sternum, but does not end in the lateral angle 
of the elliptical piece, as the skin-incision did. It is preferable 



Removal of Mammary Gland. 



3 2 5 



to earn 7 the upper incision to a point located about one and a half 
inches above, in order to leave the mamma and its adjacent tissue 
in connection with the axillary contents. While cutting down 
to the ribs the assistant must follow closely with the gauze 
compress. The whole mass containing fascia and the upper 
two-thirds of the pectoralis major muscle are now dissected 



i 

i 





Fig. 161. — Exposure of Axillary Region.- 



-(After Rotter.) 



from the base up to the lateral wound-angle, on which it 
hangs now, enveloped best in an aseptic piece of gauze. As 
soon as the incision is perfected, the base is rapidly covered 
with a large thick compress. 

The spurting arteries are now secured with haemostatic 
forceps and tied with catgut. This is done by slowly lift- 
ing up the upper compress and catching each blood-vessel 



326 Diseases of the Breast. 

separately. By lifting the compresses more and more, the 
various arteries can easily be caught in succession. The author 
feels justified in claiming that by following this plan much 
less blood is lost than by pursuing the usual method in catching 
the vessels while the incisions are made. A well- trained 
assistant will be able to compress the lower portion with 
one hand and to follow the operator with the other, while 
the upper incision is made. If the breast be very large, 
thus necessitating so large a cutting surface that one hand 
is too small to cover the whole of the bleeding area, it is 
preferable to have two assistants, one compressing the area 
below, with his two hands, and the other one following the oper- 
ator above. The hasmostasis must be very thorough, as it is 
not only a main requisite for an aseptic course, but also ren- 
ders drainage unnecessary. The whole wound-surface is now 
protected with a large gauze-pad. 

Then the whole pectoralis major muscle is extirpated. 
This is done by severing its costal insertions and splitting it 
between its costal and clavicular portions. In cases where 
the carcinoma has extended beyond the mammary capsule the 
pectoralis minor, serratus magnus, and latissimus dorsi muscles 
must also be removed. Esmarch even went as far as to 
exarticulate the arm, when he found the whole brachial plexus 
involved. 

4. The axilla is exposed by dissecting the skin as indicated 
by the preliminary mark. After the superficial fascia is split, 
the whole panniculus adiposus, together with the glands im- 
bedded in it, are extirpated in connection with the mammary 
mass. The same applies to glands situated in the supracla- 
vicular and infraclavicular fossae. 

The large vessels and nerves of the axilla must be exten- 
sively exposed and the tissues carefully examined, as not infre- 
quently chains of diseased lymphatics are discovered there. The 
contents of the axilla are dissected carefully, this being the most 



Clearing Axilla in Amputatio Mammae-. 327 

difficult part of the whole operation. To avoid excessive 
haemorrhage, a Cooper's blunt scissors can advantageously 
be used for separating the delicate tissues. Small branches 
of the axillary vein are often in connection with the glands 
and must be ligated before being dissected. Strong pulling 
must be avoided, lest the veins be emptied, and in consequence 
confounded with connective tissue, so that when they are 
divided by mistake, unexpected haemorrhage will be caused. 
The glands must not be shelled out with the fingers, as any 
crushing of them may cause traumatic dissemination of cancer- 
cells, which might explain speedy local recurrence. 

The axillary vein must be perfectly isolated. A great 
deal of patience is required in dissecting the tissues away 
from the vein without injuring it. The glands are easily 
found, as they are only slightly covered by fat-tissue. The 
other axillary vessels, the brachial plexus, and the cephalic 
vein, can easily be avoided. Although, during operation, 
the axillary vein is often teased and squeezed in the most 
regardless way, thrombosis has never been reported provided 
septic infection had been avoided. Sometimes, however, it 
occurs that it is so tightly imbedded in a mass of diseased 
glands that it is impossible to isolate it. Then the incorpo- 
rated portion must be ligated and exsected between two 
ligatures. 

Exposure of the axillary artery is but seldom necessary. 
The subscapular nerves should be preserved if possible, as 
their destruction would impair the function of the arm. When- 
ever the infraclavicular glands are infiltrated, there is a strong 
suspicion that the supraclavicular glands are infected also, 
in which case they should be extirpated too. This difficult 
procedure can only be carried out when temporary resection 
of the clavicle is performed, which is best done by sawing 
through this bone in an oblique direction. After the glands 



328 Diseases of the Breast. 

are removed, the fragments can easily be readapted and kept 
together by silver wire. 

As already said, it must be planned from the beginning 
to remove the mammary mass and the axillary contents in one 
piece, and to operate only after the areas are freely exposed, so 
that each portion can be well inspected. (See Fig. 161.) Cut- 
ting through cancerous tissue should be avoided, as this would 
be apt to disseminate cancer-cells. It is, therefore, advisable 
to use a fresh knife after the mamma is removed. 

5. The whole large wound-surface is united with silk 
sutures. First a few strong sutures, serving as relaxation 
sutures, are applied at intervals of about two inches, the needle 
being introduced three-fourths of an inch from the edge of the 
wound. The intervals are sewed up by continued silk sutures. 
Rubber as well as gauze drainage the author has given up 
entirely. It seems that in these modern times the predilection 
of a surgeon for drainage is characteristic of a lack of con- 
fidence in his own aseptic precautions. If haemostasis has 
been perfect, little oozing has to be feared. 

If so much skin had to be sacrificed, that perfect union is 
impossible, the author tried to implant skin-flaps to protect 
the deficiency. This was done, as a rule, by adding two in- 
cisions rectangularly to the original incision lines. The nearer 
the axilla they can be made, the more skin will be obtained 
(see Fig. 162). Another mode was analogous to the plastic 
operations performed for defects caused by burns (Fig. 57). ■ 

The whole area is at last covered with aseptic gauze. 
Special care is taken to fill up the axillary space. Then the 
whole side, shoulder and arm included — the latter in the 
rectangular position — is protected with a large piece of absor- 
bent moss-board, a material which, when slightly dipped into 
water, possesses the great advantage of adapting itself to the 
contours of the body, so that it serves as a real thoracic splint. 
With roller bandages this moss-splint is fastened around the 



Dressing after Amputatio Mammae. 329 

thorax and the diseased shoulder, the arm being confined to 
the side of the chest (compare Fig. 128, C). 

As a rule, it is unnecessary to change the dressing before 
one week. If there should be any evidence of great tension, 
the relaxation sutures may remain for another week. Then 
a light dressing is substituted, which leaves the arm free. 

Should there be any fever, the dressing has to be changed 
at once. If thorough aseptic precautions were taken, this occur- 
rence will be rare. The good results obtained since surgery 
of the mamma has become so radical would be still better, and 
recurrences would be less frequent, if all patients were sent to 
the surgeon at the earliest possible stage. Such extensive 
operations as extirpation of the supraclavicular glands, tem- 
porary resection of the clavicle, etc., would then but rarely be 
necessary. Why are the results of the operations for carci- 
noma of the alimentary tract so little encouraging? Only 
because the diagnosis is impossible as long as the disease is 
not well developed, as a small carcinomatous nodule cannot 
be palpated through the abdominal walls. But about the 
female breast there is no such wall, preventing the family 
physician from diagnosticating any suspicious enlargement at 
an early stage. 

If it is borne in mind that 85 per cent, of all tumors of the 
breast are of a cancerous character, the necessity of suspecting 
every growth of this organ, no matter how small it may be, is 
apparent. 

One of the disadvantages of extensive removal is that it 
creates a large defect, which can be covered only by an addi- 
tional plastic operation. Some surgeons prefer skin grafting 
and others allow the gap to fill up by granulation. 

As seen above, it is a common feature of all the valuable 
methods of amputatio mammas that the operation is begun 
with an elliptical or oval incision around the breast. To this, 
as a rule, further incisions are added in different directions. 



33° 



Diseases of the Breast. 



The general tendency is to cover the large wound produced 
by the extensive removal of mamma, plus surrounding tissue, 
by drawing in skin tissue from above and from the side. In 
the great majority of cases tension is caused by the more or 
less forcible apposition of the flaps. This is frequently fol- 




Fig. 162. — Flap Distribution for Covering Large Defect after Extensive 
Removal of Carcinomatous Mamma. 

lowed by separation of the sutures as well as by irregular 
cicatrization, the latter itself being a provoking moment for 
early recurrence of a malignant neoplasm. Lateral elongation 
of the elliptical incision somewhat diminishes the tension. 
For that purpose the author devised the formation of a lateral 



Author's Method of Amputatio Mammae. 331 

flap (Fig. 162), which has done him good service in a few 
cases. 1 Still, the result was not altogether satisfactory to him, 
wherefore he selected another way of procedure, considering 
especially that below the mamma there is an abundance of in- 
tegumental material. This fact, which might be utilized for 
covering a considerable defect, has, to his knowledge, not 
been appreciated — at least not in a methodical manner, 
although the idea is rather obvious. 

In carrying out these considerations the author began by 
giving his incision line around the breast the form of a rec- 
tangle (Fig. 163). The interior line of the rectangle is con- 




Fig. 163. — Lines of Incision in Author's Method. 



tinued on both ends to the extent of about three inches. The 
same is done with the lower end of the external side, while 
the upper exterior end is extended along the outer margin of 
the pectoralis major muscle up to its humeral insertion. The 
axilla itself is not touched, in order to avoid cicatrization in 
the axilla, which is apt to produce oedema brachii. 

After the rectangle, including the whole breast, is excised 
the upper skin flap is formed and reflected (Fig. 164) . Thus the 
area of operation is fully exposed. The principles of prepara- 

1 "Clinical Recorder," October, 1896. 



33 2 



Diseases of the Breast. 



tion (pricking, etc.) and of haemostasis are the same as described 
on page 324. Whether the fascia and the upper layer of the 
pectoralis major muscle only are removed, or whether, prefer- 




Fig. 164. — Flaps Reflected and Pectoralis Major Muscle Directed Up at 
Its Humeral Insertion. 




Fig. 165. — Area op Operation after Removal of Pectoralis Major Muscle 
and Isolation of Axillary Vessels. 



ably, the radical operation is performed (Fig. 165), the principle 
of access remains the same. The author does not dispute the 
propriety of the less radical method in selected cases, especially 
when the carcinoma is of recent origin and very small; but 



Authors Method of Removal of Breast. 333 



even in this event he would insist upon the complete removal of 
the outer margin of the pectoralis major muscle, because it 
generally covers one or more infiltrated glands, from which 
lymphatics lead to the axilla. If they are overlooked a speedy 
recurrence may be expected (compare Fig. 143). 

In general, the author is in favor of the most radical pro- 
cedures, coinciding with the views of Halsted. They would be 
severing of the pectoralis major muscle from its clavicular and 
costal attachments as well as from its humeral insertion, re- 
moving the pectoralis minor muscle, furthermore dissecting 




Fig. 166. — Flaps Brought into Apposition. 

away the axillary contents, so that the vessels are completely 
isolated, also cleaning the posterior wall of the axilla after 
spreading out the tissues on the latissimus dorsi, subscapularis, 
and teres major muscles (compare Fig. 161). 

Now the lower flap is lifted up and reflected. By gently 
drawing the upper flap downward and the lower flap upward 
one can feel, without tension, whether apposition can be 
attained. If there be any tension the lower flap is made 
longer by extending the incision line on both sides. The 
straight shape of the flaps greatly facilitates exact coaptation 
(Fig. 166). 



334 



Diseases of the Breast. 




Fig. 167. — Appearance Immediately after Operation. 




Fig. 168. — Appearance One Week after Operation. 



Rontgen Treatment of Carcinoma Mammae. 335 

The wound margins are united by thin catgut. Both ends 
of the cross-line are strengthened by the introduction of the 
marginal relaxation suture, consisting of silk. Into the upper 
end of the oblique incision line a small wick may be inserted 
sometimes in order to drain the axilla for a day or two (Fig. 167) . 

In the cases operated upon after this method the area of 
operation appeared completely movable after the lapse of 
several weeks, the cicatrices showing no adherence whatever, 
and as far as the cosmetic result is concerned, it distinguishes 
itself favorably from any of the author's previous ones (Fig. 
168). 



THE RONTGEN TREATMENT OF CARCINOMA MAMMAS. 

The palliative as well as the post-operative treatment of 
carcinoma of the breast by the Rontgen rays has become a 
recognized method (compare Figs. 169, 170, 171, 172, 173, 174, 
175, 176). In the deep-seated forms, of course, the strength of 
the rays decreases so much that only a limited influence is 
exerted. There is also a regressive metamorphosis observed in 
the deeper tissues of the body, but only under extremely favor- 
able circumstances a cure would be expected. That even deep- 
seated neoplasms may be influenced is not denied, but such in- 
fluence is not intense enough to promise more than a slight 
amelioration. Ne quid nimis I Extravagant promises will 
discredit the new and delicate field of Rontgenotherapy. In 
spite of the fact, however, that integumental carcinoma yields to 
the Rontgen therapy, the author would consider it extremely un- 
wise to leave to the rays that which can be done more quickly and 
more effectively with the scalpel — namely, extensive removal. 

But irradiation should be considered in the after-treatment 
as well as in inoperable cases. Even after a thorough operation 
of carcinoma, cells are often left in the deeper strata which 
cannot be reached by the surgical knife. We must consider 



33 6 Diseases of the Breast. 

that in the majority of cases the recurrence of carcinoma is 
caused by the epithelial cells of the primarily affected area, 
and but rarely by those of the secondary foci. Local recur- 
rence, the most frequent form, is always produced by the car- 
cinomatous cells which were left back at the operation, while 




Fig. 169. — Ulcerating Carcinoma Mamile (Recurrence). 

the indirect type originates from neighboring tissue, which 
at the time of the operation appeared to be normal, but in 
fact carried the embryonic elements of carcinomatous infection. 
A carcinomatous portion, however, left at the time of 
operation must not necessarily always be the cause of further 
infection. The vis medicatrix natures often attempts to secure 



Recurrent Carcinoma Mammae. 



337 



a natural protection by surrounding the cancer alveoli with 
giant cells, which, as microscopic examination shows, start 
a regressive metamorphosis analogous to the well-known 
healing processes in tuberculosis It is the abundance of the 
epithelial toxines which prepares the soil for the new invasion 




Fig. 170. — Case Illustrated by Fig. 169, Exclusively Treated by the 
Rontgen Method, Healed. 



and further development of the carcinoma cells. This also 
explains the rare occurrence of blood metastasis in carcinoma. 
If these cells could not really be destroyed, but if only a regres- 
sive metamorphosis was induced by the rays, a great advance 
in the treatment of this horrible disease would be madje. The 

2 3 



33* 



Diseases of the Breast. 



pioneer work in this direction was done in the United States, 
Gilman, Williams, Pusey, Grubb, Morton, Allen, Johnson, 
Skinner, and the author having been early advocates of the 
new method in carcinoma. In some cases of recurrence 
the subjective condition often improved after one exposure. In 
fact, one of the most striking signs of improvement was the 
prompt relief from pain, as in case illustrated by Fig. 171. 




Fig. 171. — Recurrence in the Axilla, Four Months after Amputatio Mam- 
m^e, in a Woman of Thirty-two Years. Palliative Treatment with 
the Rontgen Method. 



Truly, if the rays would do no more than to give relief, where 
strong narcotics failed, they would be a blessing. Microscopical 
examination shows gradual destruction of the epithelial cells. 
Nucleus and protoplasm undergo lysis. In some cells fatty 
degeneration is observed. At the same time there is a stimu- 
lative effect on the connective-tissue elements. 

In the exposures examined by the author, the irradiated 



Tissue Change after Rontgen Treatment. 



339 



areas showed colloid degeneration, the character of the tumo- 
rous texture having disappeared. It seems that this colloid 
change is characteristic for the mode of cell-metamorphosis 
after irradiation. A resemblance to glandular structure is 
shown under the microscope. In most parts the alveoli are 




'■"::'-:./.' 




Fig. 172. — Recurrent Carcinoma in a Woman of Twenty-eight Years, 
Treated by the Rontgen Method with Temporary Success after it 
Became Inoperable. 



completely filled with epithelial cells, so that in some places 
they appear like alveolar carcinoma. Some areas have 
undergone degeneration, their epithelial cells not taking 
on the stain the same as others. The cells have diminished 



34o 



Diseases of the Breast 



in size, and the degenerated area, except the nuclei, appears 
coarsely granular. Changes of the same nature are observed 
in the epithelium of the skin covering the tumor (also due to 
the action of the rays). In some parts of the necrotic area a 





Fig. 173. — Recurrence of Fibrocarcinoma in the Stitch-canals (see Small 
Nodules) Nine Months after Removal of Breast for Scirrhus. (In- 
cision Line after Author's Old Method.) 

Note rectangular line of incision. 

large amount of dense connective tissue and marked vascularity 
are noticed. 

In the treatment of diseases of a strictly integumental char- 
acter tentative exposures and protection of the vicinity of the 
affected area are properly advised. 



Protection in Rontgen Treatment. 



34i 



But in treating carcinoma we should be governed by entirely 
different principles. The author has emphasized repeatedly 
that nothing is more absurd than protecting the area which 
demands the influence of the cell-destroying agent, because, 
if we are convinced of the fact that, even when there is only a 




Fig. 174. — Metastasis in the Inguinal Region Two Years after Removal of 
Mammae, for Fibrocarcinoma, in a Woman of Forty Years. 

small carcinomatous nodule in the mammary gland, the su- 
perficial layer of the pectoralis major muscle contains, or may 
contain, carcinoma cells, why restrict ourselves, then, if we 
attempt to treat a nodule of this kind by the Rontgen rays, 
as is advised by some? Is it not exactly the contrary of 



342 



Diseases of the Breast. 



what we wish to achieve, if we then prevent distant carcinoma 
cells from being reached by covering the vicinity with some 
impermeable metal? We want to reach all carcinoma cells 
if we can, and the so-called shield does not shield the patient, 
but the carcinoma cells. Therefore, shields off in malignant 




Fig. 175. — Infraclavicular Recurrence of Carcinoma, Two Years after Am- 
putatio mamm.e, in a woman of seventy years, treated with palliative 
Improvement by the Rontgen Method. 



disease ! If we have made up our mind to influence the carci- 
noma cells, we must employ sufficient energy to enforce this 
result. But in severe cases, and especially in deep-seated 
tumors, we may in the beginning of the treatment use the 



Technics of Rontgen Treatment. 343 

tubular diaphragm for the circumscribed tumorous area 
besides, in order to intensify the effect of the rays. 

This does not imply, however, that the other extreme 
should be striven for. We must follow our therapeutic strat- 
egy in a determined but carefully observant manner. The 
practical modus operandi is, therefore, about the following : 

The patient suffering from recurrent or inoperable carcin- 
oma mammae is irradiated without first submitting to tentative 
exposures. The tube should be as near the tumorous area as 
possible, the distance of the tubal wall from the skin not ex- 
ceeding two inches. 

This is done for the purpose of influencing the growth 
itself as powerfully as possible. After there is a slight erythe- 
matous reaction, within the immediate vicinity of the growth, 
the distance is increased for the following seance. Thus the 
rays reach a larger surface. The area between the sternum 
and axilla must be fully exposed. When this wider field 
becomes erythematous also, the irradiation must be stopped 
for a few days until it shows signs of disappearance. It is 
not advisable to wait until the last little sign of dermatitis has 
vanished, because much valuable time may be lost by waiting. 
Repeated attacks of dermatitis may thus be endured. 

It seems to the author that the further the carcinomatous 
infiltration has extended, the more resistance to dermatitis 
exists, and consequently the less reaction takes place, the cell- 
metamorphosis lowering the irritability of the skin. This 
non-susceptibility, of course, varies with the different types 
of malignancy. It seems to be greatest in the fibrous variety 
of carcinoma. 

In severe cases and when there is little reaction the author's 
diaphragm should be used in order to concentrate the rays on 
the tumorous area until there is a circumscribed reaction. 

If there be extensive ulceration, causing retention of pus, 
Rontgen treatment must not be administered unless the area is 



344 Diseases of the Breast. 

exposed fully, and any necrotic tissue removed by the scalpel 
or sharp spoon. If this is omitted, the power of the rays is 
not only inhibited, but at the same time, toxaemia from local 
decomposition is added to cachexia — a very dangerous com- 
bination indeed. 

If the integument is concerned, soft tubes must be 
employed, but deeper infiltration requires tubes of medium 
hardness. It is obvious that for very deep-seated growths 
hard tubes should be employed, in view of their greater pene- 
tration power. But, as said above, the rays do not in their 
present capacity possess so much force in the deeper tissues of 
the body as to induce a complete regressive metamorphosis. 

The author does not maintain that the production of 
dermatitis in the treatment of malignant disease is desirable 
or a conditio sine qua non. But, with our present means, he 
regards powerful and long irradiation as a necessity, and this, 
unfortunately, entails the provocation of the dermatitis. 

The author's experience shows that whenever a dermatitis 
has appeared the size of the growth has diminished, oedema 
and pain have decreased, and the general condition of the 
patient has improved. 

In spite of extensive dermatitis, which causes a most dis- 
tressing burning and itching sensation, all patients suffering 
from malignant disease are anxious to undergo Rontgen treat- 
ment again as soon as possible. If the raison d'etre is thoroughly 
explained to the patients, they will certainly not make their 
physicians responsible for excessive burns. A patient afflicted 
with carcinoma, especially if it is inoperable, has, indeed, 
nothing to lose, and can well afford the risk of being burned. 
Will he act like the boy who threw rotten eggs at the man who 
pulled him out of the water and saved him from drowning, 
because in doing so he had pulled out a lock of hair? And 
in any case the physician is a soldier and must do his duty 
unconcerned, whether he be applauded or insulted. 



Partial Extirpation. 345 

Of course, the purely cosmetic standpoint is entirely 
different. If dermatitis, as alluded to above, occurs in the 
face of a fair lady, who simply wanted to be treated for hyper- 
trichosis, the cure proves to be worse than the disease. 

As a rule, a seance of ten minutes, repeated every second 
or third day, suffices in carcinoma mammae. Extensive and 
deeper-seated growths should be irradiated daily for the 
same length of time, and if no intense reaction appears, for 
twenty minutes. 

As soon as improvement is noted, the exposures should 
for a while be shorter and the intervals longer. Six weeks 
after recovery Rontgen treatment must be taken up again for 
a short period. 

As emphasized above, the Rontgen rays should not be 
substituted for the surgical treatment of carcinoma. It should 
not even be tried for that purpose, because a carcinomatous 
area if often irradiated becomes degenerated, and when opera- 
tion is submitted to, then union by first intention is not 
obtained. Excessive haemorrhage may also occur in the 
metamorphosed tissues. 

It should also be kept in mind that partial operations, 
which in former years were regarded as unscientific, are indi- 
cated if the after-treatment is carried on by irradiation. In 
deep-seated carcinoma an attempt should be made to remove 
as much as possible of the outer portion in order to enable the 
rays to get better access to the deeper-seated strata. For 
this end it is sometimes even advisable not to unite the wound 
margins, but to keep them open and separated, so that the 
rays do not need to penetrate the overlying tissues first, but 
attack the diseased area directly. The wound margins may 
then be united later. 

Ordinarily prophylactic irradiation should be begun as 
soon as union of the wound is obtained, and continued until 
slight reaction shows itself. 



346 



Diseases of the Breast. 



How much radical surgery in combination with the Rontgen 
treatment can do is illustrated by the case of a sixty-year-old 
patient who was presented to the American Therapeutic Society 
at its j annual meetings in 1902 and 1903. She began to suffer 
from carcinoma of the breast eleven years before. After having 




Fig. 176. — Carcinoma Mammae after Operation for Ninth Recurrence. 
(Compare Fig. 162.) 

been operated upon ten times she enjoyed good health. The 
result of the author's first operation, performed in February, 
1894, was illustrated in the " Clinical Recorder, "October, 1896. 
She had not asked medical advice until a year after the 
first signs had shown themselves. There was an extensive 



Ten Operations for Recurrence. 347 

carcinomatous area then of the left breast, the axillary glands 
also being involved. The extensive destruction and the pain 
appealed to her at last. It is self -understood that under the 
circumstances the author had to perform a very extensive 
operation, not only removing the pectoralis major muscle, 
together with the axillary glands, but also exsecting so large 
an area of adjacent integument that a plastic operation had 
to be undertaken (see Fig. 162). Recovery was perfect until 
six months later, when a small nodule appeared at the anterior 
axillary fold. This was again extensively removed. Then 
a period of euphoria followed for a whole year. In September, 

1896, a hard nodule originated near the sternum, which was 
also extirpated. Then there was no disturbance until June, 

1897, when a small nodule appeared in the axilla, which was 
extirpated by Dr. F. Torek, to whom the author is indebted 
for the following report : 

On August 7, 1897, there was pain at the site of the past 
operation. No recurrence. March 7, 1898, recurrence in 
posterior axillary line; extirpation April 11, 1899; another 
recurrence, the tumor showing about 3 centimetres in diameter; 
ichthyol-vasogen treatment. On January 16, 1900, the im- 
movable tumor has grown to the size of 8 to 9 centimetres in 
diameter. Dissection of axillary artery and ligation of the 
axillary vein. Microscopical examination by Prof. Henry J. 
Brooks; carcinoma, with much fibrous tissue. February 14th, 
wound perfectly healed. February 14, 1901, another recur- 
rence in axilla, tumor being about the size of an egg. February 
19th operation. Discharged from hospital cured March 8th. 
August 21, 1 90 1, another large node, probably starting from 
the stump of the pectoralis major muscle, is removed. Primary 
union. October 31, 1901, another operation is made in the 
pectoral region, and two nodules removed in the axillary 
region. January 13, 1902, another recurrence in the axilla 
of the size of a filbert; also one tumor below the clavicle, of 



348 Diseases of the Breast. 

the size of a walnut. A third neoplasm is observed in the left 
arm, in the former region of the pectoralis major muscle, and 
alongside the biceps muscle. None of the recurrent tumors 
is movable. Medication: Thyroid extract. In view of this 
enormous extent of the growths, the arm also being extremely 
oedematous, a tenth operation seemed to be inopportune, 
therefore the Rontgen therapy was considered now. 

Still, it seemed to be preferable to extirpate the tumor- 
ous portions, as far as it was possible, before resorting to 
irradiation. The author succeeded in removing the whole 
biceps muscle, and a part of the axillary region (Fig. 176). 

The infraclavicular tumor could not be removed in its 
entirety. The patient left St. Mark's Hospital eleven days 
afterward. The general condition had remarkably improved 
after irradiation. The infiltration below the clavicle and 
along the triceps muscle, as well as the oedema, did not dis- 
appear until extensive dermatitis of the first degree had set in. 
In June, 1903, the arm, which seemed to be fairly normal, 
began to swell again. At the same time the patient developed 
symptoms of pleuropneumonia, to which she succumbed, 
metastasis probably forming the basis of the pneumonic 
process. 

RONTGEN TREATMENT OF THORACIC SKIN-AFFECTIONS. 

Skin-affections of the thoracic region which often resist 
prolonged dermatological treatment, sometimes yield to one 
exposure to the Rontgen rays. As a rule, it is sufficient to use 
weak currents in weekly seances. (Exposure of five minutes' 
duration, tubal distance of 30 cm., 4 amp. and 20 volts.) 
Stronger currents are recommended only when there is but 
little reaction. The vacuum should be invariably low. The 
motto "Trying is better than studying," preeminently applies 
here. 

As mentioned on page 86, furuncles show a marked 



Treatment of Thoracic Skin-affections. 349 

predilection for the back, whose integumental sphere, so rich 
in sebaceous follicles, favors the formation of comedos and acne. 
There are cases of acne reported which healed after a few 
seances, the dilated blood-vessels disappearing and white 
skin-lines forming between the pustules and nodules. 

From proliferations around the acne pustules a real keloid- 
acne may arise. Sometimes they reach considerable size, in 
which case they may produce neuralgic disturbances (Figs. 177 
and 178). There being a great tendency to recurrence after 
extirpation, it is most gratifying that the Rontgen method pre- 
sented us with so powerful a therapeutic means, which is with- 
out the ill consequences the knife causes in this tormenting 
disease. 

Fig. 177 shows the chest of a man of twenty-three years, 
covered with multiple keloids. The back (Fig. 178) presents 
the same condition, the furunculous character being more 
marked here than in the front, which reflects the type of the 
keloid more markedly. Currents of moderate intensity showed 
an immediate curative influence. 

Tuberculous ulcers, lupus vulgaris, psoriasis, and acute 
as well as chronic eczema are also amenable to Rontgen treat- 
ment. 

For small circumscribed areas the use of radium is re- 
commended besides. 




Fig. 177. — Multiple Keloids, Originating prom Furunculosis, Front View. 




Fig. 178. — Multiple Keloids, Originating prom Furunculosis, Treated by 
the Rontgen Method, Back View. 

35° 



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NDEX. 



Abscess of lungs, 206 

diagnosis of, 206 

localization by Rontgen method, 

249 
treatment of, 207 
Actinomycosis of breast, 306 

of chest wall, 101 

of lungs, 211 
Adenonbroma mammae, 310 
Adenoma mammae, 311 
Air-chamber of Sauerbruch, 136 
Anaesthesia in abscess of lung, 211 
accidents in, 164 

in pyothorax, 159 
Anatomy of thoracic wall, 1 
Aneurysm of thoracic aorta, 226 
Arteries, axillary branches, 35 

of costal region, 35 

of heart, 121 
Artery, acromial thoracic, 35 

internal mammary, 35 

superior intercostal, 36 
thoracic, 35 

thoracico-dorsal, 35 
Articulations, costo-central, 26 

costo-chondral, 29 

costo-spinal, 26 

costo-sternal, 24 

costo-transverse, 27 

interchondral, 28 
Asepsis, 61, 64 
Aspiration of pericardium, 116 

of pleural effusion, 147 
Aspiratory puncture, 132 

in subphrenic abscess, 272 

syringe, 132 
Atheroma mammae, 311 
Axillary lines, 5 

Bacteria of skin, 62 

Bacteriology in pyothorax, 141, 146 

Blade of sternum, 9 

Body of ribs, 11 

Bone-formation after rib-resection, 200 

Boundary lines of thoracic cavity, 1 

Breast, diseases of, 290 

Bronchi, anatomy of, 236 

Bronchiectasis, 213 



Bronchiectatic cavity, localization of, 

by Rontgen method, 249 
Bronchoscopy, 242 

Buelau's suction method in pyothorax, 171 
Burns of chest wall, 73 

Carbuncle of chest wall, 88 
Carcinoma, aetiology of, 315 

general views, 316 

of breast, 314 

of chest, developing in scar, 81 

of chest wall, 106 
Caries of rib, 92 
Cartilages, costal, 29 
Chest wall, flatness of exterior, 60 
Chondroma mammae, 312 
Chronic mastitis, 301 

lobar, 303 
Chylothorax, 202 
Contusion of thorax, 82 
Costal region, 31 
Cysts, sebaceous, of chest wall, 10 1 

mammary, 304 

Decortication, 192 
Defects, costal, 44 
Dermoids of chest wall, 101 

intrathoracic, 222 
Dextrocardia, 259 
Diameter of thoracic cavity, 2 
Diaphragm, anatomy of, 40 

surgical diseases of, 225 

wounds of, 125 
Dislocation of rib, 73 
Drainage in pyothorax, 177 



Echinococcus causing subphrenic ab- 
scess, 278 
of chest wall, 112 
of lungs, 214 

localization of, by Rontgen 
method, 249 
Eczema of nipple, 293 
Embryonic thorax, 4 
Empyema, pleural. 137 
necessitatis, 167 



25 



3 6 9 



37o 



Index. 



Enchondroma of ribs, 105 

of sternum, 105 
Exploratory pleurotomy, 133 

principle in thoracic resection, 187 
Exterior aspect of chest, 2, 6 



Fascia, endothoracic, 34 
Fibroma of chest wall, 102 

molluscum of chest wall, 102 
Foreign bodies in respiratory passages, 239 

extraction of, 241 
Fracture of costal cartilage, 73 

of rib, 69 

of sternum, 68 
Furuncles of chest wall, 87, 349 



Galactocele, 301, 304 

Gangrene of lungs, localization of, by 

Rontgen method, 249 
Gas in subphrenic abscess, 269 
Gelatin-injection in aneurysm, 234 
Growths of chest wall, benign, 101 

malignant, 105 
Gumma of chest wall, 105 
Gunshot wounds of thorax, 67 



Hemangioma, cavernous, of chest wall, 

103 
Haemopericardium, 116 
Hemothorax, 201 
Handle of sternum, 6 
Heart, anatomy of, 120 

Rontgen method of examining, 258 
suture of, 125 
Hodgkin's disease, 108 
Hydropneumothorax, Rontgen method in , 

2 5 8 
Hydrothorax, 201 
Hypertrophy of breast, 307 



Inflammatory processes of chest wall, 

86 
Influenza bacillus in pyo thorax, 144 
Infusion, submammary, 133 
Injection treatment, 94 
Injuries of heart, 122 

of pericardium, 116 

of thoracic wall, non-penetrating, 61 
penetrating, 83 
Intercostal muscles, external, 32 
internal, ^^ 

spaces, 175 
Intramammary abscess, 300 
Intrathoracic diseases, 114 

tumors, 222 



Involution-cyst of mamma, 304 
Iodoform-injection in tuberculosis, 93 



Keloid of thoracic integument, 102 

treatment of, 348 
Kyphosis, 55 



Ligaments of thoracic bones, 24 
Lipoma of chest wall, 10 1 

mammae, 311 
Lisfranc's tubercle, 15 
Localization, 5, 249 
Lordosis, 57 
Lungs, abscess of, 206 

actinomycosis of, 217 

anatomy of, 203 

carcinoma of, 223 

echinococcus of, 214 

gangrene of, 211 

sarcoma of, 224 

surgical diseases of, 206 

tuberculosis of, 219 
Lymphangioma of chest wall, 104 
Lymphatics of axilla, 294 

of costal region, 40 



Malformations of thorax, 43 
Mamma, enlargement of, 53 

in hermaphroditism, 54 

removal of, 324 
Mammae, supernumerary, 53 
Mammillary line, 5 
Mastitis, 294 

puerperal, 297 
Mastodynia, 307 
Median line, 5 
Mediastinum, 115 

portions, 126, 127 
Moss-board as a dressing, 66, 255 
Movement of ribs, 16 
Myxoma mammae, 312 



Nevus of thoracic integument, 103 
Nerves of costal region, 40 
Neuroma of thoracic wall, 104 
Nipple, diseases of, 292 



(Esophagus, foreign bodies in, 244 
Ossification of ribs, stage of, 15 
Osteoma of breast, 312 

of chest wall, 105 
Osteomyelitic rib-abscess, 91 



Index. 



37i 



Parasternal lines, 5 

Pectoralis major muscle, anatomy of, 31 

minor muscle, anatomy of, 31 
Pectus carinatum, 60 
Pericardiotomy, 118 
Pericarditis, 72 
Pericardium, anatomy of, 114 

Rontgen method of examining, 259 
Perimetric figures of thorax, 3 
Periosteotome, author's, 154 
Phlegmon of thoracic wall, 90 
Pleura, anatomy of, 125 

diseases of, 128 

Rontgen picture of, 256 
Pleural speculum, author's, 156 

suture in abscess of lungs, 210 
Pleuritis sicca, 72 
Pleurotomy, exploratory, 133 
Pneumococcus in pyothorax, 144, 145 
Point of sternum, 10 
Pressure symptoms in injuries of heart, 123 

in serothorax, 131 
Processes, articular, of vertebrae, 20 

spinous, of vertebras, 18 

transverse, of vertebras, 19 
Prolapse of lung tissue, 85 
Protrusion of lower rib cartilages, 60 
Pseudoleukemia, 108 
Pyothorax, 137 

aetiology of, 141 

criticisms of various methods of 
diagnosis of, 148 

old cases, 180 

operation of, 151, 166 

Rontgen method in, 257 

statistics in, 177 



Recurrence of carcinoma mammae, 337 
Regeneration of ribs, illustrated by Ront- 
gen method, 199 
Resection of rib, 151 

in old cases, 181 

simultaneous, of two ribs, 158 
Respiratory passages, foreign bodies in, 

239 
Retromammary abscess, 300 
Ribs, anatomy of, 10 
cervical, 45 
operation for, 49 
Rib-shears, author's, 153 
Rontgen method in thoracic surgery, 246 
treatment of carcinoma mammae, 335 
of thoracic dermatoses, 340, 345 , 
348 



Sarcoma of breast, 312 

of chest wall, 105 
Sayre's apparatus, 59 



Scapular lines, 5 

Schede's principle in thoracic resection, 

184 
Scoliosis, 58 
Serothorax, 129 
Serratus anticus major muscle, anatomy 

of, 32 
Skin grafting in burns of chest wall, 78 
Solid masses, importance of, in pyothorax, 

156, 169, 174 
Spina bifida dorsalis, 54 
Staphylococcus in pyothorax, 144 
Sternal extremity of ribs, 11 
lines, 5 
region, 6 

muscles of, 29 
nerves of, 31 
vessels of, 29 
Sterno-costal lines, 6 
Sternum, anatomy of, 6, 23 
malformations of, 43 
representation of, by Rontgen method, 
247 
Streptococcus in pyothorax, 144, 145 
Subclavius muscle, anatomy of, 31 
Subphrenic abscess, 261 
Synostosis of ribs, caused by drainage- 
tubes, 198 
Syphilis of breast, 306 
of rib, 100 
of sternum, 100 



Thoracic aorta, aneurysm of, 226 
Trachea, anatomy of, 236 
Triangularis sterni muscle, anatomy of, 34 
Tuberculosis of breast, 305 

of lungs, 219 

of rib, 98 

of sternum, 96, 99 
Tuberculous pyothorax, 145, 162 
Tubular diaphragm in hypertrophied 

pleurae, 253, 254 
Tumors of chest wall, 101 

intrathoracic, 222 

of mammary gland, 308 



Vertebrae, thoracic, 16 

peculiarities of, 21 
Vertebral extremity of ribs, 1 1 
Vulpius' operation for costal defects, 45 



Wound-margins, protection of, 04 
Wounds of heart, 1^4 

of thoracic wall, treatment of, 61 
Wound-treatment, 04 



APR 2 190? 



